Subacute Care Surgery (was trauma activation and stratification)
Ronald Gross
Rgross at harthosp.org
Fri Oct 13 11:50:17 BST 2006
How 'bout that!
Take care, Tony.
Ron
>>> Tony Joseph <tjoseph at ihug.com.au> 10/12/2006 7:02 PM >>>
Ron
We have reached consensus
Regards
Tony
On 13/10/06 12:41 AM, "Ronald Gross" <Rgross at harthosp.org> wrote:
> Tony,
> I am gonna have to agree with you here. It does depend on where you
> are. Most important in your discussion, however, is the concept of
the
> multidisciplinary approach - and that should be the case regardless
of
> where you are and who is "in charge".
> Ron
>
>>>> Tony Joseph <tjoseph at ihug.com.au> 10/12/2006 9:33 AM >>>
> Dear Ron
> I guess it depends on where you are.
> I agree that trauma is a surgical disease but the fact remains that
> not
> many of our surgeons see it as a viable career pathway related to
> relatively
> poor remuneration, lifestyle etc and we have too many hospitals
taking
> too
> few trauma patients in my state (which requires a political
solution).
> There is only 1 surgeon in Australasia that I am aware of who is
> responsible
> for patients in Intensive Care.
> As a result the management of the trauma patient here is
> multidisciplinary
> and, although there is always room for improvement, in the main our
> outcomes are acceptable according to limited data from the
> Australasian
> National Trauma Registry ( NTR)
> Regards
> Tony
>
>
> On 12/10/06 10:30 PM, "Ronald Gross" <Rgross at harthosp.org> wrote:
>
>> Hi Tony,
>> lets make one thing clear here - Mattox is NEVER provocative.....
>> YEAH, RIGHT! ;-)
>> All kidding aside, I think that we are relatively spoiled here at
>> Hartford. We still follow the "15 minute rule" - in fact we are in
>> house and frequently beat the patient in the doors because of our
> pager
>> alert system. We also stay with the patient from arrival to ICU to
>> discharge, whether the patient gets an operation or not. And
unless
> the
>> patient really does have an isolated ortho or neurologic injury
that
>> requires surgery, the patients usually stay on our service for the
>> duration. So my comments are, clearly, coming from my point of
> bias.
>> On the other hand, if I did not believe that this is the way it
> should
>> be, I clearly would not have come here and stayed here........Now
it
> is
>> my turn to be provocative as I afffirm my very strong conviction
> that
>> trauma is a surgical disease, and should be managed by surgeons.
>> Best wishes,
>> Ron
>>>>> Tony Joseph <tjoseph at ihug.com.au> 10/10/2006 9:42 AM >>>
>> Dear Ron
>> I have only come into this late.
>> No one is arguing that if the patient needs an urgent operation ,
> then
>> the
>> surgeon should be involved from time of arrival as there is good
>> evidence
>> that the presence of a surgeon in the resus room shortens the time
> to
>> OR
>> significantly. In this country where the trauma laparotomy rate is
<
>> 5%, it
>> is relatively easy to understand why Trauma surgeons are few and
far
>> between
>> because they don;t get to operate. They don;t look after the
patient
> in
>> the
>> Intensive care unit and they don;t usually clear the cervical spine
> (
>> that
>> is usually left to the Emergency , Orthopedics or Neurosurgical
> docs).
>> The trauma team leader is usually either the ER or Intensive care
> doc,
>> so
>> the patient would be in deep trouble if we waved them "goodbye" on
>> their way
>> to ITU, OR or radiology. I am sure Ken was just being provocative
in
>> an
>> earlier post
>> Regards
>> Tony Joseph
>> Sydney, Australia
>>
>>
>> On 10/10/06 10:50 PM, "Ronald Gross" <Rgross at harthosp.org> wrote:
>>
>>> Ian,
>>>
>>> With all due respect, as I remember it, surgeons operate, and that
>>> operation is what the trauma patient needs when the bleeding is
>> audible.
>>> Surgeons also provide critical care in the ICU; who better than
> the
>>> surgeon who has just done the case, or the surgeon who might do
the
>> case
>>> in the near future, and who knows the patient intimately and
>> understands
>>> the physiology of the entire patient in front of him/her, to care
>> for
>>> that patient?
>>>
>>> As to your colleagues concept about who does trauma, I suggest
that
>> he
>>> come on board here and see just how many of the surgeons on this
> list
>> DO
>>> trauma - at the very least that fellow might have to alter his
>> misguided
>>> concept just a little bit.
>>>
>>> Best wishes,
>>> Ron
>>>
>>>>>> "Ian Seppelt" <SeppelI at wahs.nsw.gov.au> 10/9/2006 12:20 AM >>>
>>> Let me weight in to a CONSTRUCTIVE debate!
>>>
>>> Karim has already highlighted the differences between trauma
> surgery
>>> in
>>> the USA and elsewhere in the world, including the difficulty
> getting
>>> subspecialised surgeons interested in trauma.
>>>
>>> I saw that first hand when I first bought Ken Mattox's book 'Top
>>> Knife'. A senior Professor of Surgery (upper GI and oesophageal
>>> surgery,
>>> weekly oesophagectomy list, etc) came across me reading it, and I
>>> described to him the 'Top Knife / Top Gun' analogy, for training
> the
>>> 'best of the best'. "BUT", he pointed out to me, "The BEST
surgeons
>>> don't DO trauma".
>>>
>>> So given that in Australia / New Zealand / the UK etc it is
>> difficult
>>> to get senior surgeons interested in trauma (with notable
>> exceptions),
>>> for the most part it is Emergency Physicians, Intensivists and
>>> Anaesthetists that take up the slack. I'm happy to accept that
that
>> is
>>> substandard compared to having a highly trained 'Trauma Surgey
>>> Attending' present when every seriously injured patient arrives,
> but
>>> as
>>> Craig Ellis asked, where is the evidence that that is actually
>>> correct?
>>>
>>>
>>> What I need is something strong enough that even a senior
Professor
>> of
>>> Surgery will agree that the evidence supports having trauma
> surgeons
>>> present in the emergency department when the patient arrives.
>>>
>>> Or could it be that a well trained DOCTOR is what is needed,
>>> regardless
>>> of specialty, with the ability to activate emergency surgery for
> the
>>> minority of our (predominantly blunt) trauma patients who actually
>>> need
>>> an operation?
>>>
>>> Cheers, Ian
>>>
>>> Ian Seppelt FANZCA FJFICM
>>> Senior Staff Specialist
>>> Dept of Intensive Care Medicine
>>> The Nepean Hospital, PO Box 63 Penrith NSW 2751
>>> Clinical Lecturer, University of Sydney
>>>
>>>>>> karim at trauma.org 5/10/2006 6:19am >>>
>>> OK, it's possible I overstated the case for the sake of a little
>>> argument
>>> (the list has been rather quiet recently!) but there are trends
> here
>>> which I
>>> believe are important. First, clearly if you are a member of this
>>> list,
>>> attend trauma conferences, or are an attending at a level 1 trauma
>>> centre,
>>> chances are that you are committed to trauma/emergency care and
you
>>> are
>>> not
>>> the subject of my ranting. However if you consider the whole body
>> of
>>> surgeons I think the picture looks less rosy - whether you are in
>> the
>>> UK,
>>> South Africa, Australia or the US. If you do not work in a Level
>> 1/2
>>> trauma
>>> centre, if you are a resident planning on going straight in to
>> private
>>> practice, if you are a laparoscopic left adrenal surgeon, I don't
>>> believe
>>> the same zeal for trauma or emegency surgery is present. If I am
>>> totally
>>> off base, then I happily stand corrected, and certainly I was
>>> exaggerating
>>> to make the point. But the fact stands that emergency medicine
>>> developed
>>> (initially) to fill a vacuum left by surgery, and some specialties
>>> (witness
>>> cardiothoracics) are retreating to the operating room. We need to
>>> make
>>> sure
>>> trauma or acute care surgery doesn't go the same way.
>>>
>>> Karim
>>>
>>>
>>>
>>>
>>
>
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