Operating Room Resuscitations

[Jeff Mires]

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>From: Mike Smertka <medic0947969 at yahoo.com>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
>Subject: Re: Operating Room Resuscitations
>Date: Thu, 31 Jan 2008 16:07:08 -0800 (PST)
>
>   Just from reading this forum for a while I think the EM may have 
>overgrown the trauma role because surgery is not always readily willing or 
>available. I have seen where it has taken 45+ minutes for a surgeon to 
>wander down to the ED. (A&E) Not too long ago on this forum there was a 
>discussion of how to get surgeons to take trauma call. It seems logical the 
>ED would grow beyond their traditional role when they could not rely on 
>somebody else. I assume all of the surgeons here are interested in trauma, 
>and do not suffer from such apathy responding to a trauma page. But even in 
>designated "trauma" centers (in my experience level IIIs) surgery just 
>doesn't show up in time to be much help (if at all). Figure: If you get a 
>trauma page, you have no interest in trauma and work in a community 
>facility, if you delay your response, there is high likelyhood the ER 
>physician will initiate a transfer. So if The ED gets a patient, it takes 
>1/2 hour to assess, stabilize and even get the
>  transport going, another 10-20 minutes for a helicopter or a ground unit, 
>it seems reasonable an EM will be taking care of them for the better part 
>of an hour.
>
>   Obviously in a specialized trauma center the idea of a critical patient 
>in the ED so long sounds insane. But I think sometimes trauma specialists 
>are their own worst enemy. I have never met a trauma surgeon in person who 
>takes a regular interest in prehospital education or activities. I have 
>never met one in person who shows up to the ED meetings. So when there is 
>talk of what equipment to buy/need, or protocol on what to do, etc. the 
>major player is missing, so the ED does what it thinks is right. Take it 
>one step further, how long has it been since anyone here has argued the 
>merits of rapidly infused chrystalloid? But on page 76 of 7th edition ATLS: 
>it states that bleeding from external wounds is usually controlled by 
>direct pressure..... and that a PASG should not delay fluid therapy and 
>surgery may be needed. (lets face it, that sounds like the priority is 
>fluid, not surgery) on the very next page in bold print: "initial warmed 
>fluid given as rapidly as possible..."
>  it then gives the dose and finishes with "This often requires pumping 
>devices (mechanical or manual) to fluid administration sets." Is it a 
>wonder there are a bunch of rapid infusers, or prolonged ED time trying to 
>get an IV line?
>
>   The last time I attended ATLS, the course director (whom I hope to 
>someday be as skilled and knowledgable as)  opened with the phrase : "I am 
>not here to teach you how to take care of a trauma patient." So if trauma 
>experts don't teach that, how do nonexperts who are in the chain learn? 
>Moreover, he raised the point "If you cannot close a chest, please do not 
>open it." I think a very valid point, because if you let EMs open the chest 
>and they have no access to a surgeon or ICU that can deal with the 
>aftermath, what has really been done? I won't even start on BTLS or ITLS. 
>But also consider: If EMs are the ones teaching prehospital providers, what 
>you constantly teach, you ingrain in your own brain. The overall goal then 
>becomes getting to a doctor at the hospital. which to prehospital means the 
>ED. Ths also doesn't touch on places where the amount of resources the ED 
>has, far outstrips the ICU. Obviously there is no substitute for an OR, but 
>what is the surge capacity of
>  an OR or ICU compared to the surge capacity of an ED? I figure they are 
>different in different places, so no one system could possibly be "better."
>
>   I focused the discussion on trauma, but I don't see other critical 
>illnesses as any different for this.
>
>   once agan thanks for listening to my musings. I am not trying to take 
>sides, but to bring sides together.
>
>   Mike
>
>
>EM has an important role to play in every hospital, but how much should 
>they paly in major trauma or critical illness? Has the role of EM grown too 
>far beyond immediate care?
>
>Regards
>Mark F
>UK
>
>
>
>
>----- Original Message ----
>From: Matthew Reeds
>To: trauma-list at trauma.org
>Sent: Thursday, 31 January, 2008 12:05:49 PM
>Subject: Operating Room Resuscitations
>
>
>I agree Errington. I would in fact go further by saying that the ICU/HDU is 
>THE ONLY place for patients who need resuscitation but DON'T need
>the operating room (unless they are going to interventional radiology for 
>embolisation etc.)
>Further to Ken's comment on the role of the A&E/ED department "waving to 
>the patient", this I fully agree with and wholeheartedly support. However I 
>would say that the A&E does actually have ONE useful purpose - for the 
>receptionist to book the patient into the hospital. They can also ensure 
>that the order for massive transfusion packs is made IMMEDIATELY for them 
>to be sent STRAIGHT to theatre/OR for the patient (for those hospitals that 
>implement the 1:1 transfusion protocol.) I'll happily conceed that this is 
>in fact two purposes.
>Matthew
>____________________________________________________________
>KMATTOX at aol.com KMATTOX at aol.com
>Thu Jan 31 03:26:29 GMT
>BINGO. Great point. For any trauma patient that is not going to be
>able to be dismissed from the ER following minor treatment for a minor 
>injury,
>there is NO REASON TO KEEP THAT PATIENT IN THE ER ANY LONGER THAN IT TAKES 
>TO
>COMPLETE THE LOGISTICS OR PAPERWORK TO GET THEM TO THE OR, ICU, FLOOR, IR,
>OR OTHER LOCATION.
>
>Kenneth L. Mattox, MD
>Houston
>
>
>In a message dated 1/30/2008 9:23:48 P.M. Central Standard Time,
>errington at erringtonthompson.com writes:
>
>The ICU is a great place for patients who need resuscitation but DON'T need
>the operating room.
>
>E
>____________________________________________________________
>In a message dated 1/30/2008 9:23:48 P.M. Central Standard Time,
>errington at erringtonthompson.com writes:
>I would add that those patient that don't need to go to the OR but still
>need significant resuscitation maybe better in the ICU than the ER or
>anywhere else. For the most part trauma surgeons run their own ICU's.
>These are the nurses that have heard your lectures. They come to your
>conferences. They know what you want.
>
>The ICU is a great place for patients who need resuscitation but DON'T need
>the operating room.
>
>E
>
>Errington C. Thompson, MD, FACS, FCCM
>Trauma/Surgical Critical Care
>Author - Letter to America
>Asheville, NC
>
>-----Original Message-----
>From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at 
>trauma.org]
>On Behalf Of Ronald Gross
>Sent: Wednesday, January 30, 2008 6:52 AM
>To: trauma-list at trauma.org
>Subject: Re: Operating Room Resuscitations
>
>Yeah - what HE said! ;-)
>
>Matt, you and I are on the same page here - but you said it far better than
>I did - Thanks!
>
>Take care,
>Ron
>
> >>> Matthew Reeds 1/30/2008 5:27 AM >>>
>
>Mike & Ron,
>When pontificating over the treatment that I give to any patient, I always
>try to ask what I would want for myself and apply this to give the best
>treatment to each patient. I would NOT want to be in an A&E/ED 
>resuscitation
>room but would "rather" be in either theatre/OR, ITU/HDU, the ward or
>radiology (depending upon my injury) having the proper treatment that I
>need. This is what I would strive for with any of my patients.
>Therefore I see NO reason for the patient to remain in A&E/ED for
>resuscitation. As Ron says, if the patient needs surgery, then off to
>theatre/OR they go. If they need non-operative resuscitation, then off to
>ITU or HDU they go for the care required. [This frees up theatre/OR
>resources and time as Mike says if surgery is not required for better
>utilisation.] Radiology resuscitation is ONLY required for THERAPEUTIC
>intervention such as angio for pelvic haemorrhage and stabilisation (if the
>extra-peritoneal pelvic packing approach is NOT used etc.)
> >From my experience, there is NO need/role for A&E/ED resuscitation - if 
>the
>patient is that sick, then they need to be elsewhere (e.g. theatre/OR,
>ITU/HDU etc.)
>Even for major haemorrhage that requires surgery, these UNSTABLE patients
>SHOULD be rapidly transported to theatre/OR for surgery for emergency
>treatment. I would NOT NORMALLY advocate A&E/ED operating UNLESS absolutely
>necessary which has happened to me on a couple of occasions [such as 
>cardiac
>arrest secondary to IVC transection at the bifurcation from multiple stab
>wounds from a bayonet in a 19 year old male.] He had been "down" for 3 mins
>when he arrived in A&E by paramedics/EMT and there was no way we could
>transfer him to theatre/OR on the top floor (11th floor) and at the other
>end of the hospital to save him - a fault of the hospital design. Therefore
>we performed a laparotomy in the A&E/ED resus room and got him back with
>RAPID abdominal packing and then transferred to theatre just as rapidly.
>However, this should be a RARE occasion and ONLY be absolutely necessary to
>imminently save life rather than be the norm. In essence this comes down to
>clinical acumen, experience and ability of the clinician to use sound
>judgment and I agree with Mike, that if the patient doesn't need surgery,
>then theatre/OR is not the best place to resuscitate the patient - they
>should be in the ITU/HDU instead.
>
>Matthew
>Surgery U.K.
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