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A request. Can some of the trauma surgeons send a me a copy of their SOP or SOG that they use and teach to their residents /fellows what they do for DAMAGE CONTROL Surgery. That would be much appreciated: 

I am just putting a DCS SOG together for small animal veterinary trauma surgery for the care of the seriously injured canine patient. 

I believe it will be very similar to what you send with the ABC's addressed and if they require surgical intervention then the surgery will follow in the same order as practicality and common sense would dictate.  

Example is the one I am currently using minus the use of abdominal counterpressure for pelvic or retroperitonel bleeds we use. 

A Airway: if no airway get one;  what ever it takes - from simple to parasternotomy, tracheal access and tube the distal end of the severely injured intrathoracic trachea; 
B. Breathing: oxygen and ventilate and rapid TFAST..if hole seal: if severe tension pneumothorax and loosing pulses - do rapid thoracic decompression with a couple 14 g catheters, or do real rapid thoracostomy chest tube or just a make a hole on the affected side; consider full thoracotomy and cross clamp source of much air leek and bleeding: autotransfuse; reassess as volume improves and flows now heard on Doppler; fix to prevent further air leaks or bleeding. 
C:  Circulation: poor pressures and belly continuing to expand? Yes - then do a very quick AFAST to r/o gastric dilation with air and do TFAST, then ABC's I tubated and being ventilated, after vascular access 2 14s 2"g caths in peripheral vessels somewhere, volume running to keep some flow and pulses and then if continuing to deteriorate EITHER left thoracotomy and aortic cross clamping pending AFAST and TFAST findings, or a rapid celiotomy and immediate packing with aorta a celiac artery digitally compressed while blood is aspirated from the abdominal cavity and possible start autotransfusion and definitively cross clamp with Satinsky or pack off  all major bleeding sources (liver, spleen, kidney, etc)  then bring up pressures and observe for bleeding and control with what ever simple means necessary.  For complex bleeds consider catheter/balloon temporary occlusion of the vascular  source.  Note other injuries consider TA occlusion to stop visceral leaks, irrigate, place  two suction drains and continuous close rectus fascia, irrigate and staple close skin +/- a few subq's.. Using arterial Doppler flow even via esophagus to monitor aortic flows during the case with balanced anesthesia 
D. Disability: Keep on a back board until spine can be cleared - if CNS exam reveals pupil size expanding either do CT or if not available perform decompressive section craniectomy on side of midriatic pupil; fracture of spine on rads and neuro signs fit perform decompression - stabilization  - note for these CNS injuries discussion with owner pet parents needed as prognosis more concerning... 

Sure do appreciate your help and input from your experience.  

Thank  you 

Dennis T. (Tim) Crowe, DVM,

DACVS - Surgeon Emeritus

DACVECC, FCCM

Certified Firefighter, NREMT-I 


Chief of Surgery and Critical Care, Regional Institute for Veterinary Emergencies and Referrals, 2132 Amnicola Highway. Chattanooga, TN 37406. 423 698-4612   Fax.  423-694-4958. www.rivervetemergency.com 

   

Voice/fax 770-725-7938

cell 706-296-7020 


On Jul 28, 2014, at 10:35 AM, trauma-list-request at trauma.org wrote:

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Today's Topics:

  1. Autotransfusion (Christos Giannou)
  2. RE: Combat trauma (Gross, Ronald)
  3. RE: Autologous transfusion from chest (Gross, Ronald)
  4. RE: Autologous transfusion from chest (Gross, Ronald)
  5. RE: Autologous transfusion from chest (Gross, Ronald)
  6. Re: Autologous transfusion from chest (Jel Coward)
  7. RE: New level IV TC in need of expert advice: (Gross, Ronald)


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

Message: 1
Date: Mon, 28 Jul 2014 15:57:10 +0300
From: Christos Giannou <x.giannou at gmail.com>
Subject: Autotransfusion
To: trauma-list at trauma.org
Message-ID:
   <CANuRtePN73cFZ-TNHUVyAo-mAgjteNLbwKUGKc71gsdLfMevGw at mail.gmail.com>
Content-Type: text/plain; charset=UTF-8

The original posting asked how long the evacuated blood could be kept.

There are numerous reports about autotransfusion being practiced up  to 18
hours after injury, as long as the blood stayed in the thorax. Abdoment is
another story. Nobody has published about how long you can keep the blood
once evacuated, for a simple reason. As I believe Norman, Ken, and Tim have
already mentioned, if you remove the blood and want to perform
autotransfusion, then you give it immediately. Why wait?

Apart from cell-saver technology -- a totally different animal -- I believe
the problem lies with what one has put in drainage bottle. Ordinary water
will cause haemolysis of the blood; but not normal saline.

Tim uses 1 ml heparin / ml blood, to prevent clotting in the system. I have
used heparin, half-dose adenine-citrate-dextrose, and nothing at all
(depending on tactical situation during a war scenario) and have not
noticed a clinical difference. Of course, a randomised trial is out of the
question in these contexts (think the confusion reigning in Gaza, Syrian or
Iraqi hospitals today), but Tim's circumstances might possibly be better
suited.

Further study and bibliography in Volume 2 of *War Surgery: Working with
Limited Resources*, available as a freely downloadable PDF file from the
ICRC website (www.icrc.org).

cheers
christos


christos giannou
Monemvasia Lakonia
23070 Greece
tel: (+30) 27320-61772


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

Message: 2
Date: Mon, 28 Jul 2014 10:05:57 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: Combat trauma
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
   <D3B8664B81FCEF41B9679BF4FE9C723B2063FB9677 at bhsexc11.bhs.org>
Content-Type: text/plain; charset="utf-8"

Aka "Vitamin S" where S=silk!

Ronald I. Gross, MD, FACS
Chief, Division of Trauma, Acute Care Surgery & Surgical Critical Care
Baystate Medical Center
Associate Professor of Surgery
Tufts School of Medicine
759 Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Timothy Hardcastle
Sent: Saturday, July 26, 2014 2:55 AM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Combat trauma

To the uninitiated that is suture material!

Regards,
Tim
Dr Timothy Hardcastle
MB,ChB(Stell); M.Med(Chir)(Stell); PhD, FCS(SA), Trauma Surgery(HPCSA)
Head: UKZN Trauma Surgery Training Unit
Deputy Director: IALCH Trauma Service and Trauma ICU
Hardcastle at ukzn.ac.za / timothyhar at ialch.co.za
Mobile +27824681615
Postal: PostNet 27, Private Bag X05, MALVERN, 4055
Durban, South Africa

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of McSwain, Norman E
Sent: 25 July 2014 23:11
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Combat trauma

Don't forget the importance of Factor XIV

Norman

Norman McSwain, Jr. MD, FACS, NREMT-P
Professor, Tulane School of Medicine
Trauma Director, Spirit of Chairty Trauma Center. ILH Police Surgeon, New Orleans Police Department Medical Director PreHospital Trauma Life Support

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Slava Kopetskiy
Sent: Friday, July 25, 2014 2:12 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Combat trauma

Some people told us: "Celox save lives".? Our military medical providers are not so engage in wars as colleagues from NATO, so they decide to buy this stuff ?in unlimited quantities to save our guys.

I have a discussion with one of them and ask him about TCCC recomendations about tourniquet and all that John Holcomb and others do to give to every solder this simple trick.? Is there any comparisons between hemostatic agents and? tourniquets. I dont want to drink a cool aid so ?i want to hear every thought. Nowadays amount of? hemostatic agents is a lot bigger then ?tourniquets in ukrainian army. Thank you.
Best regards
Slava Kopetskiy
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------------------------------

Message: 3
Date: Mon, 28 Jul 2014 10:11:12 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: Autologous transfusion from chest
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
   <D3B8664B81FCEF41B9679BF4FE9C723B2063FB967F at bhsexc11.bhs.org>
Content-Type: text/plain; charset="us-ascii"

Jel,

Why was there a delay in transfusing the collected blood in a patient that was "somewhat shocky"?  Infusing that blood as it was collected would likely have avoided the issues you encountered.  We will immediately reinfuse collected blood, and we no longer citrate the reservoir, nor do we use any other anticoagulant.

Ron



-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Jel Coward
Sent: Saturday, July 26, 2014 11:33 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Autologous transfusion from chest

Hi all

I found a bit of a thread on this from 2009 but wonder if we can briefly
re-touch it please.

My question arises from a clinical event.

Small (great) rural unit - one nurse, one doc running the whole place -
desk, phones, the relatives/friends, coffee machine...oh, and the patient ;-)


About 800+ mls of blood out of the chest of m/cyclist (mvi)  into the
Pleur-evac - Sahara system -  autotransfusion collection bag (apologies for
the use of brand name...done in case it might be relevant).

No external leakage.

Somewhat shocky.  Not clear at this point if bleeding elsewhere.

Some O-neg TXA and all the usual.  No cross-match facility.  No surgeon

The transport team declined to use the autologous blood from the chest
because it was too old (is my understanding of the reason they stated -
someone else present wasn't sure that this was the full reason).  It was,
about 2 hours from the start of the collection.

Not using that blood was, I think, part of the transport units request to
take more O-neg from this distant small facility....that has just a few
units and cannot re-stock easily because of geography etc


There might be some other questions and issues here but my question for the
list (he says, nudging gently to avoid too much drift :)  is around the
timing of the use of that collected blood.  My understanding previously has
been that the manufacturer of the collection unit states 'up to 6 hours
from the start of the collection', but that some folks have chosen
4.....but not 2.

Any thoughts please on pros/cons of timing, salvaged blood use etc?

I am not hunting the transport team, they have a challenging job......I am
just trying to get the best info so that we can work on education and
improving care.   There was quite a negative feeling in the facility that
the blood they had thought to, and then worked to, collect. was considered
only fit for black pudding http://en.wikipedia.org/wiki/Black_pudding

Thanks for any input.

Cheers :)

jel





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----------------------------------------------------------------------
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.


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

Message: 4
Date: Mon, 28 Jul 2014 10:15:35 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: Autologous transfusion from chest
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
   <D3B8664B81FCEF41B9679BF4FE9C723B2063FB9687 at bhsexc11.bhs.org>
Content-Type: text/plain; charset="us-ascii"

" strikes me that if we have their blood and it is more than just a
little bit, and there is some evidence of volume depletion....then we
should give it back"

'Nuff said!!  :-)

Ron


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Jel Coward
Sent: Sunday, July 27, 2014 2:22 PM
To: trauma-list at trauma.org
Subject: Re: Autologous transfusion from chest

Thanks Norman and Tim

.....so powerful when talking locally to be able to add in such high level
input  (cautiously of course :)

I have seen a protocol from a semi-local facility that says that blood
recovered from the chest in such a system can be used if there is >1500 mls
lost....or more than 400mls per hour to augment the use of transfusion
blood.....
.....all of which sounds a bit daft.....a patient is shocky  (from chest
but possibly elsewhere) .....and we should wait until we have 1500mls in
the bucket....and only to augment other blood......in the small rural
facility with 3+ hour transport on a good day, with a limited supply of
O-neg that is difficult to restock...

.....strikes me that if we have their blood and it is more than just a
little bit, and there is some evidence of volume depletion....then we
should give it back

.....anyone want to counter?

Cheers - this is a great list

jel


On 14-07-27 07:38 AM, McSwain, Norman E wrote:
Tim

We probable have several deaths, not from the technique but from the major injures, the produced the hemorrhage itself. I cannot recall a single negative complication from the use of blood from the chest as an 'auto-transfusion'. Memory or "in our experience", of course, is the worst kind of evident. I will see if I can find something about this in our trauma registry.

Norman

Norman McSwain, MD, FACS
Professor of Surgery, Tulane University of Louisiana
Clinical Professor of Surgery, Louiosiana State University
Trauma Director, Spirit of Charity Trauma Center, ILH
Medical Director PreHosptial Trauma Life Support (PHTLS)
Police Surgeon, New Orleans Police Department
504 988 5111


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Timothy Hardcastle
Sent: Saturday, July 26, 2014 11:04 PM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Autologous transfusion from chest

Hi Norm - could not agree more - we use a South African designed chest tube drainage system called Sinapi that has a blood-giving set adaptor at the base and a port to add 1IU of Heparin per ml of blood to prevent clotting in the system. No adverse effects and a good few lives saved. Those who died did not die of bleeding complications, rather TBI or non-salvagable injury.

Regards,
Tim
Dr Timothy Hardcastle
MB,ChB(Stell); M.Med(Chir)(Stell); PhD, FCS(SA), Trauma Surgery(HPCSA)
Head: UKZN Trauma Surgery Training Unit
Deputy Director: IALCH Trauma Service and Trauma ICU Hardcastle at ukzn.ac.za / timothyhar at ialch.co.za Mobile +27824681615
Postal: PostNet 27, Private Bag X05, MALVERN, 4055 Durban, South Africa

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of McSwain, Norman E
Sent: 26 July 2014 18:23
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Autologous transfusion from chest

We use thoracic hemorrhage blood collected via a chest tube extremely frequently at the Spirit of Charity Trauma Center in New Orleans. Because the patient is losing it now, we replace it now. Very seldom is the delay more than 1 hour. I see no reason to wait for transfusion until later. The patient is  actively bleeding or has been actively bleeding, the blood is fresh, warm, whole blood with most of the clotting factors, most of the oncotic and red cells at the same ratio as the patient because it has immediately come from the patient.

Cell Saver blood that has been washed has significantly less clotting factors and plasma. It is not as good as fresh bleed from a chest tube

If this does not answer your question please restate your needs

Norman

Norman McSwain, MD, FACS
Professor of Surgery, Tulane University of Louisiana Clinical Professor of Surgery, Louiosiana State University Trauma Director, Spirit of Charity Trauma Center, ILH Medical Director PreHosptial Trauma Life Support (PHTLS) Police Surgeon, New Orleans Police Department
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Jel Coward
Sent: Saturday, July 26, 2014 10:33 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Autologous transfusion from chest

Hi all

I found a bit of a thread on this from 2009 but wonder if we can briefly re-touch it please.

My question arises from a clinical event.

Small (great) rural unit - one nurse, one doc running the whole place - desk, phones, the relatives/friends, coffee machine...oh, and the patient ;-)


About 800+ mls of blood out of the chest of m/cyclist (mvi)  into the Pleur-evac - Sahara system -  autotransfusion collection bag (apologies for the use of brand name...done in case it might be relevant).

No external leakage.

Somewhat shocky.  Not clear at this point if bleeding elsewhere.

Some O-neg TXA and all the usual.  No cross-match facility.  No surgeon

The transport team declined to use the autologous blood from the chest because it was too old (is my understanding of the reason they stated - someone else present wasn't sure that this was the full reason).  It was, about 2 hours from the start of the collection.

Not using that blood was, I think, part of the transport units request to take more O-neg from this distant small facility....that has just a few units and cannot re-stock easily because of geography etc


There might be some other questions and issues here but my question for the list (he says, nudging gently to avoid too much drift :)  is around the timing of the use of that collected blood.  My understanding previously has been that the manufacturer of the collection unit states 'up to 6 hours from the start of the collection', but that some folks have chosen 4.....but not 2.

Any thoughts please on pros/cons of timing, salvaged blood use etc?

I am not hunting the transport team, they have a challenging job......I am just trying to get the best info so that we can work on education and
improving care.   There was quite a negative feeling in the facility that
the blood they had thought to, and then worked to, collect. was considered only fit for black pudding http://en.wikipedia.org/wiki/Black_pudding

Thanks for any input.

Cheers :)

jel





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----------------------------------------------------------------------
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.


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

Message: 5
Date: Mon, 28 Jul 2014 10:16:12 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: Autologous transfusion from chest
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
   <D3B8664B81FCEF41B9679BF4FE9C723B2063FB9688 at bhsexc11.bhs.org>
Content-Type: text/plain; charset="iso-8859-1"

It ain't old if it is new!  Collect it and give it back.....simple, really!

Ron


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Andr? Carneiro
Sent: Sunday, July 27, 2014 2:25 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Autologous transfusion from chest

This is indeed fascinating in its simplicity.

For those who use this regularly, have there been any issues with significantly deranged electrolytes from haemolysis of "old blood" in the bag?


Sent from my mobile. Bear with me.

On 27 Jul 2014, at 19:22, Jel Coward <jel at wildmedic.org> wrote:

Thanks Norman and Tim

.....so powerful when talking locally to be able to add in such high level input  (cautiously of course :)

I have seen a protocol from a semi-local facility that says that blood recovered from the chest in such a system can be used if there is >1500 mls lost....or more than 400mls per hour to augment the use of transfusion blood.....
.....all of which sounds a bit daft.....a patient is shocky  (from chest but possibly elsewhere) .....and we should wait until we have 1500mls in the bucket....and only to augment other blood......in the small rural facility with 3+ hour transport on a good day, with a limited supply of O-neg that is difficult to restock...

.....strikes me that if we have their blood and it is more than just a little bit, and there is some evidence of volume depletion....then we should give it back

.....anyone want to counter?

Cheers - this is a great list

jel


On 14-07-27 07:38 AM, McSwain, Norman E wrote:
Tim

We probable have several deaths, not from the technique but from the major injures, the produced the hemorrhage itself. I cannot recall a single negative complication from the use of blood from the chest as an 'auto-transfusion'. Memory or "in our experience", of course, is the worst kind of evident. I will see if I can find something about this in our trauma registry.

Norman

Norman McSwain, MD, FACS
Professor of Surgery, Tulane University of Louisiana
Clinical Professor of Surgery, Louiosiana State University
Trauma Director, Spirit of Charity Trauma Center, ILH
Medical Director PreHosptial Trauma Life Support (PHTLS)
Police Surgeon, New Orleans Police Department
504 988 5111


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Timothy Hardcastle
Sent: Saturday, July 26, 2014 11:04 PM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Autologous transfusion from chest

Hi Norm - could not agree more - we use a South African designed chest tube drainage system called Sinapi that has a blood-giving set adaptor at the base and a port to add 1IU of Heparin per ml of blood to prevent clotting in the system. No adverse effects and a good few lives saved. Those who died did not die of bleeding complications, rather TBI or non-salvagable injury.

Regards,
Tim
Dr Timothy Hardcastle
MB,ChB(Stell); M.Med(Chir)(Stell); PhD, FCS(SA), Trauma Surgery(HPCSA)
Head: UKZN Trauma Surgery Training Unit
Deputy Director: IALCH Trauma Service and Trauma ICU Hardcastle at ukzn.ac.za / timothyhar at ialch.co.za Mobile +27824681615
Postal: PostNet 27, Private Bag X05, MALVERN, 4055 Durban, South Africa

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of McSwain, Norman E
Sent: 26 July 2014 18:23
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Autologous transfusion from chest

We use thoracic hemorrhage blood collected via a chest tube extremely frequently at the Spirit of Charity Trauma Center in New Orleans. Because the patient is losing it now, we replace it now. Very seldom is the delay more than 1 hour. I see no reason to wait for transfusion until later. The patient is  actively bleeding or has been actively bleeding, the blood is fresh, warm, whole blood with most of the clotting factors, most of the oncotic and red cells at the same ratio as the patient because it has immediately come from the patient.

Cell Saver blood that has been washed has significantly less clotting factors and plasma. It is not as good as fresh bleed from a chest tube

If this does not answer your question please restate your needs

Norman

Norman McSwain, MD, FACS
Professor of Surgery, Tulane University of Louisiana Clinical Professor of Surgery, Louiosiana State University Trauma Director, Spirit of Charity Trauma Center, ILH Medical Director PreHosptial Trauma Life Support (PHTLS) Police Surgeon, New Orleans Police Department
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Jel Coward
Sent: Saturday, July 26, 2014 10:33 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Autologous transfusion from chest

Hi all

I found a bit of a thread on this from 2009 but wonder if we can briefly re-touch it please.

My question arises from a clinical event.

Small (great) rural unit - one nurse, one doc running the whole place - desk, phones, the relatives/friends, coffee machine...oh, and the patient ;-)


About 800+ mls of blood out of the chest of m/cyclist (mvi)  into the Pleur-evac - Sahara system -  autotransfusion collection bag (apologies for the use of brand name...done in case it might be relevant).

No external leakage.

Somewhat shocky.  Not clear at this point if bleeding elsewhere.

Some O-neg TXA and all the usual.  No cross-match facility.  No surgeon

The transport team declined to use the autologous blood from the chest because it was too old (is my understanding of the reason they stated - someone else present wasn't sure that this was the full reason).  It was, about 2 hours from the start of the collection.

Not using that blood was, I think, part of the transport units request to take more O-neg from this distant small facility....that has just a few units and cannot re-stock easily because of geography etc


There might be some other questions and issues here but my question for the list (he says, nudging gently to avoid too much drift :)  is around the timing of the use of that collected blood.  My understanding previously has been that the manufacturer of the collection unit states 'up to 6 hours from the start of the collection', but that some folks have chosen 4.....but not 2.

Any thoughts please on pros/cons of timing, salvaged blood use etc?

I am not hunting the transport team, they have a challenging job......I am just trying to get the best info so that we can work on education and
improving care.   There was quite a negative feeling in the facility that
the blood they had thought to, and then worked to, collect. was considered only fit for black pudding http://en.wikipedia.org/wiki/Black_pudding

Thanks for any input.

Cheers :)

jel





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Message: 6
Date: Mon, 28 Jul 2014 07:22:00 -0700
From: Jel Coward <jel at wildmedic.org>
Subject: Re: Autologous transfusion from chest
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
   <CAGwnjo8hERHYHDG5Lrtp9kMeQn_tvuB_WHPPmbmSixJLUPKPLQ at mail.gmail.com>
Content-Type: text/plain; charset=UTF-8

Thanks again to all.

The 'delay', I think, was not really intended.   The collection unit holds
a litre - is is a pre-anticoagulated unit designed for purpose.  So there
was the filling time...and O-neg was hanging.....and arranging transport
can be horribly time consuming for the 1 doc and 1-2 nurses in the place
whilst trying to do all the clinical stuff (yes....some folks are working
really hard to address that :)

What isn't available there is a device to allow 'reinfusion as collected'

Cheers

jel


On 28 July 2014 07:11, Gross, Ronald <Ronald.Gross at baystatehealth.org>
wrote:

Jel,

Why was there a delay in transfusing the collected blood in a patient that
was "somewhat shocky"?  Infusing that blood as it was collected would
likely have avoided the issues you encountered.  We will immediately
reinfuse collected blood, and we no longer citrate the reservoir, nor do we
use any other anticoagulant.

Ron



-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:
trauma-list-bounces at trauma.org] On Behalf Of Jel Coward
Sent: Saturday, July 26, 2014 11:33 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Autologous transfusion from chest

Hi all

I found a bit of a thread on this from 2009 but wonder if we can briefly
re-touch it please.

My question arises from a clinical event.

Small (great) rural unit - one nurse, one doc running the whole place -
desk, phones, the relatives/friends, coffee machine...oh, and the patient
;-)


About 800+ mls of blood out of the chest of m/cyclist (mvi)  into the
Pleur-evac - Sahara system -  autotransfusion collection bag (apologies for
the use of brand name...done in case it might be relevant).

No external leakage.

Somewhat shocky.  Not clear at this point if bleeding elsewhere.

Some O-neg TXA and all the usual.  No cross-match facility.  No surgeon

The transport team declined to use the autologous blood from the chest
because it was too old (is my understanding of the reason they stated -
someone else present wasn't sure that this was the full reason).  It was,
about 2 hours from the start of the collection.

Not using that blood was, I think, part of the transport units request to
take more O-neg from this distant small facility....that has just a few
units and cannot re-stock easily because of geography etc


There might be some other questions and issues here but my question for the
list (he says, nudging gently to avoid too much drift :)  is around the
timing of the use of that collected blood.  My understanding previously has
been that the manufacturer of the collection unit states 'up to 6 hours
from the start of the collection', but that some folks have chosen
4.....but not 2.

Any thoughts please on pros/cons of timing, salvaged blood use etc?

I am not hunting the transport team, they have a challenging job......I am
just trying to get the best info so that we can work on education and
improving care.   There was quite a negative feeling in the facility that
the blood they had thought to, and then worked to, collect. was considered
only fit for black pudding http://en.wikipedia.org/wiki/Black_pudding

Thanks for any input.

Cheers :)

jel





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Some Open-Source and Creative Commons interests.....
The CARE Course http://www.theCAREcourse.ca
Wilderness Medicine Twitter account <http://twitter.com/#%21/wemsiint>
WEMSI-International http://WEMSI-International.org
OSCAR open-source EMR http://OSCARcanada.org


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

Message: 7
Date: Mon, 28 Jul 2014 10:34:53 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: New level IV TC in need of expert advice:
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
   <D3B8664B81FCEF41B9679BF4FE9C723B2063FB968F at bhsexc11.bhs.org>
Content-Type: text/plain; charset="utf-8"

OK - consider my buttons pushed.  I have, in the past, posted J.D. Richardson's Presidential Address to the AAST in 1999.  Very simply put, he asserted that trauma surgeons are GENERAL SURGEONS that have a particular dedication to taking care of the injured patient, but they are by no means restricted to only trauma, and that general surgeons have the ability to care for the injured, even if they don't call themselves "trauma surgeons".

I have always thought that this "I can't do this" claim (which, by the way, usually comes over the phone at 2 AM on a weekend) should be taken into account when credentialing or recredentialing a surgeon at his or her hospital.  Simply put, if you are an ABS (American Board of Surgery or frankly any Board of Surgery anywhere in the world) certified general surgeon, then you have satisfied the Board in your initial and in subsequent re-certification exams that you are a safe and capable GENERAL SURGEON.  That means that you have no excuse when it comes time to caring for a patient who clearly needs a GENERAL SURGEON.  If you incapable of or uncomfortable of caring for a bleeding trauma patient, then it only stands to reason that you would also be incapable of or uncomfortable with caring for a patient that is bleeding after a misadventure during an elective colectomy. If that is indeed the case, then you should NOT be given privileges to operate.

Kinda like the orthopedic surgeon who can do joint replacements all day long, but won't come in to care for an open tib/fib because he isn't able to care for trauma.  REALLY????

Donning my Kevlar vest now and awaiting incoming fire......................

Ron


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Rwolfer
Sent: Sunday, July 27, 2014 3:13 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: New level IV TC in need of expert advice:

One of problems is that while the " level 4 surgeons" can do elective cases quite easily. It seems when the perf tic, perf ulcer, acute appy, and trauma pts come into er they all of a sudden cant do and often refuse to see
Rw

Sent from my iPhone so I can reply quickly so please forgive any errors

On Jul 27, 2014, at 12:07 PM, "Gross, Ronald" <Ronald.Gross at baystatehealth.org> wrote:

Pret,

" When a surgeon at a Level IV center is involved in the management of major injuries in the ED it should be in support of".....................THE PATIENT.  Period.  End of statement.

What that means is that the patient who can survive transport is assessed by the surgeon, only critical interventions necessary to make sure that the patient is safe during transport are done and the patient is loaded onto a rig.  For the patient who cannot survive transport without an operation (and the patient ended up in the Level IV because there was no other place around or the EMS folks thought the patient wouldn?t make the trip to the TC) the surgeon needs to see the patient, operate on the patient and stabilize him/her in the OR if at all possible and only then transport the patient.  Any surgeon who has graduated from a surgical residency should at the very least be able to stop most bleeding.  Should and most are the operative words here, and we are going to have to accept the fact that at times this heroic surgery may amount to nothing but a ?sterile autopsy".

Ron


Ronald I. Gross, MD, FACS
Chief, Division of Trauma, Acute Care Surgery & Surgical Critical Care
Baystate Medical Center
Associate Professor of Surgery
Tufts School of Medicine
759 Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Bjorn, Pret
Sent: Thursday, July 24, 2014 9:47 AM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: New level IV TC in need of expert advice:

I think we're failing here to acknowledge that most of the critical tasks of rural trauma systems fall very properly into the scope and responsibility of non-surgeons at non-tertiary facilities.  This is a crucial truth: systematic care of major or multisystem trauma at a level IV center should focus pretty much exclusively on stabilization and transfer (SEE ALSO: Rural Trauma Team Development Course).  The rest is counter-systematic ad-libbing, and an invitation to chronic mediocrity and occasional disaster.

When a surgeon at a Level IV center is involved in the management of major injuries in the ED, it should be in support of that paradigm.  Anything else is either wasted time, or bona fide heroism.  If your system tolerates the former or relies on the latter, it's not really much of a system at all.

Pret Bjorn, RN
Bangor, ME USA



-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of William Bromberg
Sent: Thursday, July 24, 2014 9:16 AM
To: trauma-list at trauma.org
Subject: Re: New level IV TC in need of expert advice:

I thought that the concept of a level IV trauma center was basically to bring a hospital with limited services  "into the system" so they could participate with performance improvement and research such as entering patients into the registry and TQIP.

I am in agreement with Dr. Mattox and Dr. Gross that if you want to act like a level III, become a level III. If the hospital doesn't want to be a level III I'm not sure that I agree that the staff should be held to the accountability to level III.

Bill Bromberg
Sent from my iPhone

On Jul 24, 2014, at 8:49, "Gross, Ronald" <Ronald.Gross at baystatehealth.org> wrote:

Exactly!

Typed by thumbs and sent from my iPhone.

On Jul 23, 2014, at 9:36 PM, "KMATTOX at aol.com" <KMATTOX at aol.com> wrote:

If you are functioning as a 3, then become a 3


In a message dated 7/23/2014 6:35:13 P.M. Central Daylight Time,
Wendy.Rife at providence.org writes:

Thank  you all for your thoughts, you've made some good points.  I see the
"carrot" being the way to go...  We only see about 450 trauma cases per
year, this is out of our total volume of 30,500.  Last year we averaged 1
FTTA per month.   I know that this is peanuts compared to other  facilities,
but the next closest facility is 27 miles up the freeway.  It  makes sense to
remain a level IV.

Bill, we are held to level III  standards because we offer surgical
services 24/7.  This has proven to be  difficult to explain why to my surgeons,
they seem to be stuck on  it!

Wendy

-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of trauma-list-request at trauma.org
Sent: Wednesday, July 23, 2014  3:12 PM
To: trauma-list at trauma.org
Subject: trauma-list Digest, Vol 133,  Issue 11

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
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When replying, please edit your Subject  line so it is more specific
than "Re: Contents of trauma-list  digest..."


Today's Topics:

1. Re: New level IV  TC in need of expert advice: (William Bromberg)
2. RE: New  level IV TC in need of expert advice: (Gross, Ronald)
3. Re:  trauma-list Digest, Vol 133, Issue 10 (jrhmdtraum at aol.com)
4.  RE: trauma-list Digest, Vol 133, Issue 10 (Gross, Ronald)
5.  Re: New level IV TC in need of expert advice: (William  Bromberg)
6. Re: trauma-list Digest, Vol 133, Issue 10  (William Bromberg)
7. Re: New level IV TC in need of expert  advice: (KMATTOX at aol.com)
8. Re: trauma-list Digest, Vol 133,  Issue 10  (Candy)


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

Message:  1
Date: Wed, 23 Jul 2014 14:31:21 -0400
From: "William Bromberg"  <brombwi1 at memorialhealth.com>
Subject: Re: New level IV TC in need of  expert advice:
To: <trauma-list at trauma.org>
Message-ID:  <53CFC7860200003A00038170 at mhgw2.mh.com>
Content-Type: text/plain;  charset=US-ASCII

Then why does the requirements for a level IV trauma  center not include
any Surgery capability?

Bill Bromberg
Sent from  my iPhone

On Jul 23, 2014, at 14:29, "Gross, Ronald"
<Ronald.Gross at baystatehealth.org> wrote:

" Trauma may be  a surgical disease but does "stabilize and ship" have to
be?"

Yes.  This becomes eminently clear when a patient dies in transport or
in  the ED of the receiving hospital because someone missed a couple of key
signs  that would have taken the patient to the OR for stabilization BEFORE
transport.

Ronald I. Gross, MD, FACS
Chief, Division  of Trauma, Acute Care Surgery & Surgical Critical Care
Baystate  Medical Center
Associate Professor of Surgery
Tufts School of  Medicine
759 Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of William Bromberg
Sent: Wednesday, July 23, 2014 2:13 PM
To: Trauma-List  [TRAUMA.ORG]
Subject: RE: New level IV TC in need of expert  advice:

I have a question. Criteria for a Level IV center does  not require
surgeons to be on call at all so it seems to me that the surgeons  are objecting
to being part of a resuscitation over and above the extent  mandated. Is
this not correct?

If so then you are definitely  going to need the "carrot" approach as
opposed to the stick. I know for sure  that the level IV in GA does not have
surgeons on call at night 7 nights a  week and does not require them to come
to trauma resuscitations at  al.

Trauma may be a surgical disease but does "stabilize and  ship" have to
be?

Bill Bromberg

"Gross, Ronald" <Ronald.Gross at baystatehealth.org> 7/23/2014 2:02 PM
The best way to fix your issues is to incorporate your 2  surgeons as the
key to a solution and not see them as a problem.  That is  often easier to
say than to do, but it is definitely doable as long as you  remember that if
you are going to ask for stuff you need to give stuff back in  return.

Let's start with the assumption that most "general  surgeons" didn't go
into trauma and acute care surgery because they really  didn't want to do
trauma.  We all know that most trauma care today will  be non-operative, as
long as you didn't train with or practice with the likes  of McSwain,
Demetriades or Velmahos - and now that George is at the MGH, aka  "Man's Greatest
Hospital" (LOL) the same may now apply to him as well!   As such, you are
correct in assuming that your 2 surgeons are not going to  want to come into the
hospital and spend all night with a patient that will  never see your OR and
will occupy your surgeon just long enough to see them  into an ambulance as
they are sent on to the regional trauma center; your  surgeons will be
quite happy to leave that management to their EM  colleagues.  IT is imperative
that your surgeons are reminded that trauma  is a surgical disease, and that
as good as your ED docs might be, they are NOT  surgeons, and they do not
have the same kno
wl
edge base and extent  of training that they 9 your surgeons) have.  I am
going to assume that  your surgeons are conscientious and caring physicians;
they should easily see,  therefore, that their involvement in the patients
that get transferred is just  as if not more important as it is for the ones
that go to the OR when one  looks at outcomes; there are more papers out
there than you can count that  have shown that surgeon involvement in patient
care and in systems of care  leads to far better outcomes than one sees
without the involvement of  surgeons.

If your surgeons have never taken ATLS, pay for them  to take it, and pay
for them to stay current in it.  Offer your surgeons  the opportunity to
take the Rural Trauma Team Development Course (RTTDC) and  to then bring the
Trauma Evaluation & Management (TEAM) Course to your  region.  Start a
Performance Improvement & Patient Safety (PIPS)  program that is focused on your
trauma program and that is driven by your  surgeons, and that involves all
that are needed to care for the injured  patient in your hospital.
Acknowledge the involvement of and the  contributions from your surgeons as THEY build
your program with your  assistance and with the cooperation of you trauma
program manager, remembering  that the carrot works better than the stick
(most of the time).   Establish a relationship with the hospital(s) that you
send YOUR patients to  so that there is a two way communication between your
trauma programs that  focuses on outcomes and performance improvement.  Begin
to look at  bad
ou
tcomes as cases where all can find opportunities for  improvement in
care, and get away from the urge to "lay  blame".

I could go on and on, but I will stop here, and offer  my contact
information to you should you want to talk further off  line.

Best of luck as you move forward into the world of  better outcomes
through surgeon involvement in trauma care!

Ronald I. Gross, MD, FACS
Chief, Division of Trauma, Acute Care  Surgery & Surgical Critical Care
Baystate Medical Center
Associate Professor of Surgery
Tufts School of Medicine
759  Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original  Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Rife, Wendy A
Sent: Wednesday, July 23, 2014 11:01 AM
To:  trauma-list at trauma.org
Subject: New level IV TC in need of expert  advice:

New level IV TC in need of expert  advice:

Situation- How do other level IV facilities balance  meeting trauma
standards and engaging the surgeons when resources are  thin?

Background- Most of our traumatic injuries are  stabilized and
transferred to higher level facilities.  Therefore, our 2  surgeons who provide 24/7
coverage, are usually not directly involved in the  care of these patients.
Last year, we had a total of 11 full trauma  activations with 1 disposition
to the OR.  In the past, the ER doctor  would essentially only call the
surgeon to the bedside when diagnostics were  completed (on full trauma
activations).   Creating a pattern of  "surgeon no shows" and "delayed response".
With the turnover of  trauma program manager, this practice is no longer
acceptable and is highly  discouraged.

Assessment- We only have 2 surgeons, they are  called to the full trauma
activations with the expectation of assisting the ER  doctor with the
stabilization of these patients.  Rarely do these  patients go to the OR.  The
surgeons are interested in the patients that  they take to the OR (not the
patient who is being shipped out).  I see  this is as a huge problem- we need
involved surgeons in order for the survival  of our trauma program!!!

Recommendations- I'm looking for  insight from other level IV facilities
as well advice from trauma  surgeons.

Wendy Rife RN BSN CEN | Trauma Coordinator
Southwest Washington | PCH Emergency Room
914 S Scheuber Rd |  Centralia WA 98532
t: 360.827.6621 | f: 360.827-6620  |





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

Message:  2
Date: Wed, 23 Jul 2014 14:37:56 -0400
From: "Gross, Ronald"  <Ronald.Gross at baystatehealth.org>
Subject: RE: New level IV TC in  need of expert advice:
To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:
<D3B8664B81FCEF41B9679BF4FE9C723B2063FB930B at bhsexc11.bhs.org>
Content-Type:  text/plain; charset="us-ascii"

I have no clue - but because it isn't  required doesn't mean it isn't a
better way.  Look, we have all  complained about the "unfunded mandates" that
have been "forced upon us" by  the ACS COT "Optimal Resources" documents over
the years, and at the same  time, the number of ACS COT verified trauma
centers continues to increase, and  outcomes continue to show improvement from
trauma centers and trauma systems  when compared hospitals that care for
injured patients outside a trauma system  with "unfunded mandates" that have
forced us to render the best care  possible.

The bottom line is simple - just 'cause you haven't been  forced to do
"something" doesn't mean that that "something" ain't the right  way to go!

Ronald I. Gross, MD, FACS
Chief, Division of Trauma,  Acute Care Surgery & Surgical Critical Care
Baystate Medical  Center
Associate Professor of Surgery
Tufts School of Medicine
759  Chestnut Street
Springfield, MA  01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original  Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of William Bromberg
Sent:  Wednesday, July 23, 2014 2:31 PM
To: trauma-list at trauma.org
Subject: Re:  New level IV TC in need of expert advice:

Then why does the  requirements for a level IV trauma center not include
any Surgery  capability?

Bill Bromberg
Sent from my iPhone

On Jul 23,  2014, at 14:29, "Gross, Ronald"
<Ronald.Gross at baystatehealth.org>  wrote:

" Trauma may be a surgical disease but does "stabilize  and ship" have to
be?"

Yes.  This becomes eminently clear  when a patient dies in transport or
in the ED of the receiving hospital  because someone missed a couple of key
signs that would have taken the patient  to the OR for stabilization BEFORE
transport.

Ronald I. Gross,  MD, FACS
Chief, Division of Trauma, Acute Care Surgery & Surgical  Critical Care
Baystate Medical Center
Associate Professor of  Surgery
Tufts School of Medicine
759 Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original  Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of William Bromberg
Sent: Wednesday, July 23, 2014 2:13 PM
To: Trauma-List  [TRAUMA.ORG]
Subject: RE: New level IV TC in need of expert  advice:

I have a question. Criteria for a Level IV center does  not require
surgeons to be on call at all so it seems to me that the surgeons  are objecting
to being part of a resuscitation over and above the extent  mandated. Is
this not correct?

If so then you are definitely  going to need the "carrot" approach as
opposed to the stick. I know for sure  that the level IV in GA does not have
surgeons on call at night 7 nights a  week and does not require them to come
to trauma resuscitations at  al.

Trauma may be a surgical disease but does "stabilize and  ship" have to
be?

Bill Bromberg

"Gross, Ronald" <Ronald.Gross at baystatehealth.org> 7/23/2014 2:02 PM
The best way to fix your issues is to incorporate your 2  surgeons as the
key to a solution and not see them as a problem.  That is  often easier to
say than to do, but it is definitely doable as long as you  remember that if
you are going to ask for stuff you need to give stuff back in  return.

Let's start with the assumption that most "general  surgeons" didn't go
into trauma and acute care surgery because they really  didn't want to do
trauma.  We all know that most trauma care today will  be non-operative, as
long as you didn't train with or practice with the likes  of McSwain,
Demetriades or Velmahos - and now that George is at the MGH, aka  "Man's Greatest
Hospital" (LOL) the same may now apply to him as well!   As such, you are
correct in assuming that your 2 surgeons are not going to  want to come into the
hospital and spend all night with a patient that will  never see your OR and
will occupy your surgeon just long enough to see them  into an ambulance as
they are sent on to the regional trauma center; your  surgeons will be
quite happy to leave that management to their EM  colleagues.  IT is imperative
that your surgeons are reminded that trauma  is a surgical disease, and that
as good as your ED docs might be, they are NOT  surgeons, and they do not
have the same kno
wl
edge base and extent  of training that they 9 your surgeons) have.  I am
going to assume that  your surgeons are conscientious and caring physicians;
they should easily see,  therefore, that their involvement in the patients
that get transferred is just  as if not more important as it is for the ones
that go to the OR when one  looks at outcomes; there are more papers out
there than you can count that  have shown that surgeon involvement in patient
care and in systems of care  leads to far better outcomes than one sees
without the involvement of  surgeons.

If your surgeons have never taken ATLS, pay for them  to take it, and pay
for them to stay current in it.  Offer your surgeons  the opportunity to
take the Rural Trauma Team Development Course (RTTDC) and  to then bring the
Trauma Evaluation & Management (TEAM) Course to your  region.  Start a
Performance Improvement & Patient Safety (PIPS)  program that is focused on your
trauma program and that is driven by your  surgeons, and that involves all
that are needed to care for the injured  patient in your hospital.
Acknowledge the involvement of and the  contributions from your surgeons as THEY build
your program with your  assistance and with the cooperation of you trauma
program manager, remembering  that the carrot works better than the stick
(most of the time).   Establish a relationship with the hospital(s) that you
send YOUR patients to  so that there is a two way communication between your
trauma programs that  focuses on outcomes and performance improvement.  Begin
to look at  bad
ou
tcomes as cases where all can find opportunities for  improvement in
care, and get away from the urge to "lay  blame".

I could go on and on, but I will stop here, and offer  my contact
information to you should you want to talk further off  line.

Best of luck as you move forward into the world of  better outcomes
through surgeon involvement in trauma care!

Ronald I. Gross, MD, FACS
Chief, Division of Trauma, Acute Care  Surgery & Surgical Critical Care
Baystate Medical Center
Associate Professor of Surgery
Tufts School of Medicine
759  Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original  Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Rife, Wendy A
Sent: Wednesday, July 23, 2014 11:01 AM
To:  trauma-list at trauma.org
Subject: New level IV TC in need of expert  advice:

New level IV TC in need of expert  advice:

Situation- How do other level IV facilities balance  meeting trauma
standards and engaging the surgeons when resources are  thin?

Background- Most of our traumatic injuries are  stabilized and
transferred to higher level facilities.  Therefore, our 2  surgeons who provide 24/7
coverage, are usually not directly involved in the  care of these patients.
Last year, we had a total of 11 full trauma  activations with 1 disposition
to the OR.  In the past, the ER doctor  would essentially only call the
surgeon to the bedside when diagnostics were  completed (on full trauma
activations).   Creating a pattern of  "surgeon no shows" and "delayed response".
With the turnover of  trauma program manager, this practice is no longer
acceptable and is highly  discouraged.

Assessment- We only have 2 surgeons, they are  called to the full trauma
activations with the expectation of assisting the ER  doctor with the
stabilization of these patients.  Rarely do these  patients go to the OR.  The
surgeons are interested in the patients that  they take to the OR (not the
patient who is being shipped out).  I see  this is as a huge problem- we need
involved surgeons in order for the survival  of our trauma program!!!

Recommendations- I'm looking for  insight from other level IV facilities
as well advice from trauma  surgeons.

Wendy Rife RN BSN CEN | Trauma Coordinator
Southwest Washington | PCH Emergency Room
914 S Scheuber Rd |  Centralia WA 98532
t: 360.827.6621 | f: 360.827-6620  |





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If you  are not the intended recipient, please be aware that any
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Communication of electronic protected health information  (ePHI) is
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secure. The HIPAA Security Rule allows for patients to initiate  communication of
personal health information over this medium and for  providers to respond
accordingly with the understanding that privacy of  communication is not
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------------------------------

Message:  3
Date: Wed, 23 Jul 2014 15:02:45 -0400 (EDT)
From: "jrhmdtraum at aol.com"  <jrhmdtraum at aol.com>
Subject: Re: trauma-list Digest, Vol 133, Issue  10
To: trauma-list at trauma.org
Message-ID:  <8D174BFD1A9EDE8-1F9C-1FF59 at webmail-m155.sysops.aol.com>
Content-Type:  text/plain; charset="us-ascii"


Agree with David


Message:  6
Date: Wed, 23 Jul 2014 12:58:40 -0400
From: David Napoliello  <nappio at aol.com>
Subject: Re: New level IV TC in need of expert  advice:
To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:  <B9C5A419-8F3D-4893-B1B5-38F22F837CCB at aol.com>
Content-Type:  text/plain;        charset=windows-1252

AGREE.
Furthermore, the fact that these   TWO surgeons  provide 24/7 365 coverage
for
your hospital seems to  have been glossed over.  HALF of their entire year
allows
your entire  hospital to operate and be licensed, and if there is so little
Trauma,  maybe it is indeed because the hospital should not be a level 4
center.
Not  trying to be argumentative but pointing out the obvious.  Stabilizing
and
transferring is basically in the ER docs job description and a surgeon
showing
up for PR seems to be counter productive.
David Andrew  Napoliello MD FACS
nappio at aol.com






John R Hall,  MD, FACS, FCCM
Professor of  Surgery






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

Message:  4
Date: Wed, 23 Jul 2014 15:08:14 -0400
From: "Gross, Ronald"  <Ronald.Gross at baystatehealth.org>
Subject: RE: trauma-list Digest,  Vol 133, Issue 10
To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:
<D3B8664B81FCEF41B9679BF4FE9C723B2063FB932A at bhsexc11.bhs.org>
Content-Type:  text/plain; charset="us-ascii"

Hmmmm..........the day I do ANYTHING for  PR is the day I become a lawyer!
(Sorry, Candy).  I did not gloss over  the facts sited below, and I also
realize that not EVERY trauma patient needs  the surgeon present.  Those that
meet the ACS COT highest level of triage  criteria should initially be
managed by a surgeon, and from what I read in the  initial post, that is going to
be very infrequent.

Again, I will go  back to my initial premise - we do our best for the best
outcomes, and NOT for  the best PR, thank you very much!!  And on that note,
off I go into the  wild blue yonder.

Ronald I. Gross, MD, FACS
Chief, Division of  Trauma, Acute Care Surgery & Surgical Critical Care
Baystate Medical  Center
Associate Professor of Surgery
Tufts School of Medicine
759  Chestnut Street
Springfield, MA  01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original  Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of  jrhmdtraum at aol.com
Sent: Wednesday, July 23, 2014 3:03 PM
To:  trauma-list at trauma.org
Subject: Re: trauma-list Digest, Vol 133, Issue  10


Agree with David


Message: 6
Date: Wed, 23 Jul 2014  12:58:40 -0400
From: David Napoliello <nappio at aol.com>
Subject:  Re: New level IV TC in need of expert advice:
To: "Trauma-List  [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:  <B9C5A419-8F3D-4893-B1B5-38F22F837CCB at aol.com>
Content-Type:  text/plain;        charset=windows-1252

AGREE.
Furthermore, the fact that these   TWO surgeons  provide 24/7 365 coverage
for
your hospital seems to  have been glossed over.  HALF of their entire year
allows
your entire  hospital to operate and be licensed, and if there is so little
Trauma,  maybe it is indeed because the hospital should not be a level 4
center.
Not  trying to be argumentative but pointing out the obvious.  Stabilizing
and
transferring is basically in the ER docs job description and a surgeon
showing
up for PR seems to be counter productive.
David Andrew  Napoliello MD FACS
nappio at aol.com






John R Hall,  MD, FACS, FCCM
Professor of Surgery




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CONFIDENTIALITY NOTICE: This  e-mail communication and any attachments may
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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
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------------------------------

Message:  5
Date: Wed, 23 Jul 2014 15:52:34 -0400
From: "William Bromberg"  <brombwi1 at memorialhealth.com>
Subject: Re: New level IV TC in need of  expert advice:
To: <trauma-list at trauma.org>
Message-ID:  <53CFDA990200003A0003817B at mhgw2.mh.com>
Content-Type: text/plain;  charset=US-ASCII

But you shouldn't find it surprising that surgeons  that signed up to be at
a level IV trauma center, knowing or expecting that  their presence was not
required at resuscitations would be nonplussed to find  that all of a
sudden their presence is in fact required.

Bill  Bromberg
Sent from my iPhone

On Jul 23, 2014, at 14:39, "Gross,  Ronald"
<Ronald.Gross at baystatehealth.org> wrote:

I have  no clue - but because it isn't required doesn't mean it isn't a
better  way.  Look, we have all complained about the "unfunded mandates" that
have been "forced upon us" by the ACS COT "Optimal Resources" documents
over  the years, and at the same time, the number of ACS COT verified trauma
centers  continues to increase, and outcomes continue to show improvement
from trauma  centers and trauma systems when compared hospitals that care for
injured  patients outside a trauma system with "unfunded mandates" that have
forced us  to render the best care possible.

The bottom line is simple -  just 'cause you haven't been forced to do
"something" doesn't mean that that  "something" ain't the right way to go!

Ronald I. Gross, MD,  FACS
Chief, Division of Trauma, Acute Care Surgery & Surgical  Critical Care
Baystate Medical Center
Associate Professor of  Surgery
Tufts School of Medicine
759 Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original  Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of William Bromberg
Sent: Wednesday, July 23, 2014 2:31 PM
To:  trauma-list at trauma.org
Subject:
=?utf-8?B?UmU6IE5ldyBsZXZlbCBJViBUQyBpbiBuZWVkIG9mIGV4cGVydCBhZHZpY2U6==?>
Then why does the requirements for a level IV trauma center not include
any  Surgery capability?

Bill Bromberg
Sent from my  iPhone

On Jul 23, 2014, at 14:29, "Gross, Ronald"
<Ronald.Gross at baystatehealth.org> wrote:

"  Trauma may be a surgical disease but does "stabilize and ship" have
to  be?"

Yes.  This becomes eminently clear when a  patient dies in transport or
in the ED of the receiving hospital because  someone missed a couple of key
signs that would have taken the patient to the  OR for stabilization BEFORE
transport.

Ronald I.  Gross, MD, FACS
Chief, Division of Trauma, Acute Care Surgery  & Surgical Critical Care
Baystate Medical Center
Associate Professor of Surgery
Tufts School of  Medicine
759 Chestnut Street
Springfield, MA  01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of William  Bromberg
Sent: Wednesday, July 23, 2014 2:13 PM
To:  Trauma-List [TRAUMA.ORG]
Subject: RE: New level IV TC in need of  expert advice:

I have a question. Criteria for a Level  IV center does not require
surgeons to be on call at all so it seems to me  that the surgeons are objecting
to being part of a resuscitation over and  above the extent mandated. Is
this not correct?

If so  then you are definitely going to need the "carrot" approach as
opposed to the  stick. I know for sure that the level IV in GA does not have
surgeons on call  at night 7 nights a week and does not require them to come
to trauma  resuscitations at al.

Trauma may be a surgical disease  but does "stabilize and ship" have to
be?

Bill  Bromberg

"Gross, Ronald"  <Ronald.Gross at baystatehealth.org> 7/23/2014 2:02 PM
The best way to fix your issues is to incorporate  your 2 surgeons as
the key to a solution and not see them as a problem.   That is often easier to
say than to do, but it is definitely doable as long as  you remember that
if you are going to ask for stuff you need to give stuff  back in return.

Let's start with the assumption that  most "general surgeons" didn't go
into trauma and acute care surgery because  they really didn't want to do
trauma.  We all know that most trauma care  today will be non-operative, as
long as you didn't train with or practice with  the likes of McSwain,
Demetriades or Velmahos - and now that George is at the  MGH, aka "Man's Greatest
Hospital" (LOL) the same may now apply to him as  well!  As such, you are
correct in assuming that your 2 surgeons are not  going to want to come into the
hospital and spend all night with a patient  that will never see your OR
and will occupy your surgeon just long enough to  see them into an ambulance
as they are sent on to the regional trauma center;  your surgeons will be
quite happy to leave that management to their EM  colleagues.  IT is imperative
that your surgeons are reminded that trauma  is a surgical disease, and
that as good as your ED docs might be, they are NOT  surgeons, and they do not
have the same kn
o
wl
edge  base and extent of training that they 9 your surgeons) have.  I am
going  to assume that your surgeons are conscientious and caring
physicians; they  should easily see, therefore, that their involvement in the patients
that get  transferred is just as if not more important as it is for the
ones that go to  the OR when one looks at outcomes; there are more papers out
there than you  can count that have shown that surgeon involvement in patient
care and in  systems of care leads to far better outcomes than one sees
without the  involvement of surgeons.

If your surgeons have never  taken ATLS, pay for them to take it, and
pay for them to stay current in  it.  Offer your surgeons the opportunity to
take the Rural Trauma Team  Development Course (RTTDC) and to then bring the
Trauma Evaluation &  Management (TEAM) Course to your region.  Start a
Performance Improvement  & Patient Safety (PIPS) program that is focused on your
trauma program and  that is driven by your surgeons, and that involves all
that are needed to care  for the injured patient in your hospital.
Acknowledge the involvement of  and the contributions from your surgeons as THEY
build your program with your  assistance and with the cooperation of you trauma
program manager, remembering  that the carrot works better than the stick
(most of the time).   Establish a relationship with the hospital(s) that you
send YOUR patients to  so that there is a two way communication between your
trauma programs that  focuses on outcomes and performance improvement.
Begin to look at  bad
ou
tcomes as cases where all can find opportunities  for improvement in
care, and get away from the urge to "lay  blame".

I could go on and on, but I will stop here,  and offer my contact
information to you should you want to talk further off  line.

Best of luck as you move forward into the world  of better outcomes
through surgeon involvement in trauma  care!

Ronald I. Gross, MD, FACS
Chief,  Division of Trauma, Acute Care Surgery & Surgical Critical  Care
Baystate Medical Center
Associate Professor of  Surgery
Tufts School of Medicine
759 Chestnut  Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Rife, Wendy A
Sent: Wednesday, July 23, 2014 11:01 AM
To:  trauma-list at trauma.org
Subject: New level IV TC in need of expert  advice:

New level IV TC in need of expert  advice:

Situation- How do other level IV facilities  balance meeting trauma
standards and engaging the surgeons when resources are  thin?

Background- Most of our traumatic injuries are  stabilized and
transferred to higher level facilities.  Therefore, our 2  surgeons who provide 24/7
coverage, are usually not directly involved in the  care of these patients.
Last year, we had a total of 11 full trauma  activations with 1 disposition
to the OR.  In the past, the ER doctor  would essentially only call the
surgeon to the bedside when diagnostics were  completed (on full trauma
activations).   Creating a pattern of  "surgeon no shows" and "delayed response".
With the turnover of  trauma program manager, this practice is no longer
acceptable and is highly  discouraged.

Assessment- We only have 2 surgeons, they  are called to the full trauma
activations with the expectation of assisting  the ER doctor with the
stabilization of these patients.  Rarely do these  patients go to the OR.  The
surgeons are interested in the patients that  they take to the OR (not the
patient who is being shipped out).  I see  this is as a huge problem- we need
involved surgeons in order for the survival  of our trauma program!!!

Recommendations- I'm looking  for insight from other level IV facilities
as well advice from trauma  surgeons.

Wendy Rife RN BSN CEN | Trauma  Coordinator
Southwest Washington | PCH Emergency Room
914 S Scheuber Rd | Centralia WA 98532
t: 360.827.6621 | f:  360.827-6620  |





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Message:  6
Date: Wed, 23 Jul 2014 15:54:54 -0400
From: "William Bromberg"  <brombwi1 at memorialhealth.com>
Subject: Re: trauma-list Digest, Vol  133, Issue 10
To: <trauma-list at trauma.org>
Message-ID:  <53CFDB1B0200003A00038184 at mhgw2.mh.com>
Content-Type: text/plain;  charset=US-ASCII

The people that meet the highest level of activation  should not go to a
level IV center at all.

Bill Bromberg
Sent from  my iPhone

On Jul 23, 2014, at 15:09, "Gross, Ronald"
<Ronald.Gross at baystatehealth.org> wrote:

Hmmmm..........the day I do ANYTHING for PR is the day I become a
lawyer!  (Sorry, Candy).  I did not gloss over the facts sited below, and I also
realize that not EVERY trauma patient needs the surgeon present.  Those
that meet the ACS COT highest level of triage criteria should initially be
managed by a surgeon, and from what I read in the initial post, that is going
to be very infrequent.

Again, I will go back to my initial  premise - we do our best for the
best outcomes, and NOT for the best PR, thank  you very much!!  And on that
note, off I go into the wild blue  yonder.

Ronald I. Gross, MD, FACS
Chief, Division of  Trauma, Acute Care Surgery & Surgical Critical Care
Baystate  Medical Center
Associate Professor of Surgery
Tufts School of  Medicine
759 Chestnut Street
Springfield, MA 01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of  jrhmdtraum at aol.com
Sent: Wednesday, July 23, 2014 3:03 PM
To:  trauma-list at trauma.org
Subject:
=?utf-8?B?UmU6IHRyYXVtYS1saXN0IERpZ2VzdCwgVm9sIDEzMywgSXNzdWUgMTA===?>

Agree with David


Message: 6
Date: Wed, 23 Jul  2014 12:58:40 -0400
From: David Napoliello  <nappio at aol.com>
Subject: Re: New level IV TC in need of expert  advice:
To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:  <B9C5A419-8F3D-4893-B1B5-38F22F837CCB at aol.com>
Content-Type:  text/plain;    charset=windows-1252

AGREE.
Furthermore, the fact that these  TWO surgeons  provide 24/7 365
coverage for
your hospital seems to have been glossed over.  HALF  of their entire
year allows
your entire hospital to operate and be  licensed, and if there is so
little
Trauma, maybe it is indeed because  the hospital should not be a level 4
center.
Not trying to be  argumentative but pointing out the obvious.
Stabilizing and
transferring is basically in the ER docs job description and a surgeon
showing
up for PR seems to be counter productive.
David Andrew  Napoliello MD FACS
nappio at aol.com






John R  Hall, MD, FACS, FCCM
Professor of  Surgery




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

Message:  7
Date: Wed, 23 Jul 2014 17:01:50 -0400 (EDT)
From:  KMATTOX at aol.com
Subject: Re: New level IV TC in need of expert  advice:
To: trauma-list at trauma.org
Message-ID:  <6c421.666f28f3.41017cbe at aol.com>
Content-Type: text/plain;  charset="US-ASCII"


If there is a level IV trauma facility and there  are surgeons available in
any way and those surgeons are not in the loop of  patient evaluation, or
surgeons are not involved in assessment either by  telecommunication or
other
means, then this "LEVEL IV TRAUMA FACILITY"  simply should go  away.

In today's world, there are many  innovative ways to improve patient  care.
Just as an example, an  earlier post stated something about a  level iv
facility "stabilizing"  a patient.   If that "stabilization"  is aimed to
merely
start IVs, flood the patient with crystalloids, and over   hydrate, over
radiate (with CT Scans) etc. a patient who never needed  these  things, AND
it
takes time, and makes the patient worse, then  the patient should  have
NEVER
have stopped there and the initial  ambulance should have already  known
about permissive hypotenision's  value and merely taken the patient on down
the
road.

I do  believe that LEVEL IV jargon is massively over used and equally  over
rated.

Kenneth L. Mattox, MD




In a message  dated 7/23/2014 2:53:11 P.M. Central Daylight  Time,
brombwi1 at memorialhealth.com writes:

But you  shouldn't  find it surprising that surgeons that signed up to be at
a level IV   trauma center, knowing or expecting that their presence was not
required  at  resuscitations would be nonplussed to find that all of a
sudden  their presence  is in fact required.

Bill Bromberg
Sent from my  iPhone

On Jul 23, 2014, at 14:39, "Gross,  Ronald"
<Ronald.Gross at baystatehealth.org> wrote:

I  have no clue  - but because it isn't required doesn't mean it isn't  a
better way.   Look, we have all complained about the "unfunded  mandates"
that
have been  "forced upon us" by the ACS COT "Optimal  Resources" documents
over the years,  and at the same time, the number  of ACS COT verified
trauma
centers continues  to increase, and  outcomes continue to show improvement
from trauma centers and  trauma  systems when compared hospitals that care
for
injured patients  outside  a trauma system with "unfunded mandates" that
have
forced us  to render the  best care possible.

The bottom line is  simple - just 'cause  you haven't been forced to do
"something"  doesn't mean that that "something"  ain't the right way to  go!

Ronald I. Gross, MD, FACS
Chief, Division of  Trauma, Acute Care Surgery & Surgical Critical  Care
Baystate  Medical Center
Associate Professor of  Surgery
Tufts  School of Medicine
759 Chestnut Street
Springfield, MA  01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original   Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of William Bromberg
Sent: Wednesday, July 23, 2014 2:31  PM
To:  trauma-list at trauma.org
Subject:
=?utf-8?B?UmU6IE5ldyBsZXZlbCBJViBUQyBpbiBuZWVkIG9mIGV4cGVydCBhZHZpY2U6==?>
Then why does the requirements for a level IV trauma center not   include
any Surgery capability?

Bill Bromberg
Sent  from my iPhone

On Jul 23, 2014, at 14:29,  "Gross, Ronald"
<Ronald.Gross at baystatehealth.org>  wrote:

"  Trauma may be a surgical disease but  does "stabilize and ship" have
to  be?"

Yes.  This becomes eminently clear when a  patient dies in transport  or
in the ED of the receiving hospital because  someone missed a  couple of key
signs that would have taken the patient to the  OR for  stabilization BEFORE
transport.

Ronald I.   Gross, MD, FACS
Chief, Division of Trauma, Acute Care  Surgery  & Surgical Critical Care
Baystate Medical  Center
Associate Professor of Surgery
Tufts  School of  Medicine
759 Chestnut Street
Springfield, MA  01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of William  Bromberg
Sent: Wednesday, July 23, 2014  2:13 PM
To:  Trauma-List [TRAUMA.ORG]
Subject:  RE: New level IV TC in need of  expert advice:

I  have a question. Criteria for a  Level IV center does not  require
surgeons to be on call at all so it seems to  me that the  surgeons are
objecting
to being part of a resuscitation over and   above the extent mandated. Is
this not correct?

If  so  then you are definitely going to need the "carrot" approach  as
opposed to the  stick. I know for sure that the level IV in GA does  not
have
surgeons on call  at night 7 nights a week and does not  require them to
come
to trauma  resuscitations at  al.

Trauma may be a surgical  disease but does  "stabilize and ship" have to
be?

Bill  Bromberg

"Gross, Ronald"   <Ronald.Gross at baystatehealth.org> 7/23/2014 2:02  PM
The best way to fix your issues is to  incorporate  your 2 surgeons as
the key to a solution and not see them  as a problem.   That is often
easier to
say than to do, but it is  definitely doable as long as  you remember that
if you are going to  ask for stuff you need to give stuff  back in  return.

Let's start with the assumption that   most "general surgeons" didn't go
into trauma and acute care surgery  because  they really didn't want to do
trauma.  We all know that  most trauma care  today will be non-operative, as
long as you didn't  train with or practice with  the likes of McSwain,
Demetriades or  Velmahos - and now that George is at the  MGH, aka "Man's
Greatest
Hospital" (LOL) the same may now apply to him as  well!   As such, you are
correct in assuming that your 2 surgeons are not   going to want to come
into the
hospital and spend all night with a  patient  that will never see your OR
and will occupy your surgeon just  long enough to  see them into an
ambulance
as they are sent on to the  regional trauma center;  your surgeons will be
quite happy to leave  that management to their EM  colleagues.  IT is
imperative
that  your surgeons are reminded that trauma  is a surgical disease,  and
that as good as your ED docs might be, they are NOT  surgeons, and  they do
not
have the same kn
o
wl
edge  base  and extent of training that they 9 your surgeons) have.  I
am
going  to assume that your surgeons are conscientious and  caring
physicians; they  should easily see, therefore, that their  involvement in
the patients
that get  transferred is just as if not  more important as it is for the
ones that go to  the OR when one looks  at outcomes; there are more papers
out
there than you  can count that  have shown that surgeon involvement in
patient
care and in  systems of  care leads to far better outcomes than one sees
without the   involvement of surgeons.

If your surgeons have  never  taken ATLS, pay for them to take it, and
pay for them to stay  current in  it.  Offer your surgeons the opportunity
to
take the  Rural Trauma Team  Development Course (RTTDC) and to then bring
the
Trauma Evaluation &  Management (TEAM) Course to your  region.  Start a
Performance Improvement  & Patient Safety  (PIPS) program that is focused
on your
trauma program and  that is  driven by your surgeons, and that involves all
that are needed to  care  for the injured patient in your hospital.
Acknowledge the  involvement of  and the contributions from your surgeons
as THEY
build  your program with your  assistance and with the cooperation of you
trauma
program manager, remembering  that the carrot works better than  the stick
(most of the time).   Establish a relationship with the  hospital(s) that
you
send YOUR patients to  so that there is a two way  communication between
your
trauma programs that  focuses on outcomes  and performance improvement.
Begin to look at  bad
ou
tcomes as cases where all can find opportunities  for  improvement in
care, and get away from the urge to "lay   blame".

I could go on and on, but I will stop  here,  and offer my contact
information to you should you want to talk  further off  line.

Best of luck as you move  forward into the world  of better outcomes
through surgeon involvement  in trauma care!

Ronald I. Gross, MD, FACS
Chief, Division of Trauma,  Acute Care Surgery & Surgical Critical  Care
Baystate Medical  Center
Associate Professor  of Surgery
Tufts School of  Medicine
759 Chestnut  Street
Springfield, MA  01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of Rife, Wendy A
Sent: Wednesday, July 23, 2014 11:01  AM
To:  trauma-list at trauma.org
Subject: New level  IV TC in need of expert  advice:

New level IV TC  in need of expert  advice:

Situation- How do  other level IV facilities  balance meeting trauma
standards and  engaging the surgeons when resources are  thin?

Background- Most of our traumatic injuries are  stabilized  and
transferred to higher level facilities.  Therefore, our 2   surgeons who
provide 24/7
coverage, are usually not directly involved in  the  care of these patients.
Last year, we had a total of 11 full  trauma  activations with 1 disposition
to the OR.  In the past,  the ER doctor  would essentially only call the
surgeon to the bedside  when diagnostics were  completed (on full  trauma
activations).   Creating a pattern of  "surgeon no  shows" and "delayed
response".
With the turnover of  trauma program  manager, this practice is no longer
acceptable and is highly   discouraged.

Assessment- We only have 2  surgeons,  they are called to the full trauma
activations with the  expectation of  assisting the ER doctor with the
stabilization of  these patients.  Rarely  do these patients go to the OR.
The
surgeons are interested in the  patients that they take to the OR  (not the
patient who is being shipped  out).  I see this is as a  huge problem- we
need
involved surgeons in  order for the survival of  our trauma program!!!

Recommendations- I'm  looking for insight from other level IV facilities
as  well advice  from trauma surgeons.

Wendy Rife RN BSN  CEN |  Trauma Coordinator
Southwest Washington | PCH Emergency   Room
914 S Scheuber Rd | Centralia WA 98532
t:   360.827.6621 | f: 360.827-6620  |





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Message:  8
Date: Thu, 24 Jul 2014 06:11:44 +0800
From: Candy  <candy.marcus at gmail.com>
Subject: Re: trauma-list Digest, Vol 133,  Issue 10
To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:  <7A3DEAC7-7700-4471-94A3-CFD84DA818A4 at gmail.com>
Content-Type:  text/plain;       charset=us-ascii

Ron, I am in  alaska on vacation taking the route of the Harriman
expedition, besides I am a  nurse first so don't take anything too seriously that I
hear from doctors...ok  I love you all, I learn so much from lurking. I
appreciate you all.
Just so  you know the lawyer thing came afterward when I realized we needed
a strong  voice in defense, which is what I do.

Sent from my iPad

On  Jul 24, 2014, at 3:08, "Gross, Ronald"
<Ronald.Gross at baystatehealth.org>  wrote:

Hmmmm..........the day I do ANYTHING for PR is the day  I become a
lawyer! (Sorry, Candy).  I did not gloss over the facts sited  below, and I also
realize that not EVERY trauma patient needs the surgeon  present.  Those that
meet the ACS COT highest level of triage criteria  should initially be
managed by a surgeon, and from what I read in the initial  post, that is going
to be very infrequent.

Again, I will go  back to my initial premise - we do our best for the
best outcomes, and NOT for  the best PR, thank you very much!!  And on that
note, off I go into the  wild blue yonder.

Ronald I. Gross, MD, FACS
Chief,  Division of Trauma, Acute Care Surgery & Surgical Critical Care
Baystate Medical Center
Associate Professor of Surgery
Tufts  School of Medicine
759 Chestnut Street
Springfield, MA  01199
413-794-4022
ronald.gross at baystatehealth.org


-----Original  Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of  jrhmdtraum at aol.com
Sent: Wednesday, July 23, 2014 3:03 PM
To:  trauma-list at trauma.org
Subject: Re: trauma-list Digest, Vol 133, Issue  10


Agree with David


Message:  6
Date: Wed, 23 Jul 2014 12:58:40 -0400
From: David Napoliello  <nappio at aol.com>
Subject: Re: New level IV TC in need of expert  advice:
To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:  <B9C5A419-8F3D-4893-B1B5-38F22F837CCB at aol.com>
Content-Type:  text/plain;    charset=windows-1252

AGREE.
Furthermore, the fact that these  TWO surgeons  provide 24/7 365
coverage for
your hospital seems to have been glossed over.  HALF  of their entire
year allows
your entire hospital to operate and be  licensed, and if there is so
little
Trauma, maybe it is indeed because  the hospital should not be a level 4
center.
Not trying to be  argumentative but pointing out the obvious.
Stabilizing and
transferring is basically in the ER docs job description and a surgeon
showing
up for PR seems to be counter productive.
David Andrew  Napoliello MD FACS
nappio at aol.com






John R  Hall, MD, FACS, FCCM
Professor of  Surgery




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