Operating Room Resuscitations

[MARK FORREST]

Matt, Ken, Errington, Ron etc,
What music to me ears.....for years we have being tying to pry patients out of the claws of the resus room. Sadly, whilst the paramedics no longer 'stay and play' we have simply moved the problem to the resus room! Drips, level one infusors, excessive investigations and so it goes on......surely the role of the ER is rapid triage, commence life saving care and GO!! 
 
In the UK we have a 4 hour target for patients to leave the Emergency Dept. Incredibly, this also applies to the resus room.....4 hours!! If any patient needs for hours to commence resus or to organise further care then there is something very wrong with the system yet day after day we get patients referred to the ICU after 3hrs 50 mins who are far from sorted.....stay and play stikes again!
 
What's worse is the fact that we constantly hear how they cannot make the target time and the departments are so busy. Surely by rapidly dispatching the sickest and most dependent patients then they can get on with managing all those others still waiting?
 
Can we just get a good triage sister, make a decision about the route of dispatch and then get them off to theatre, ICU, angio, all within minutes? Well, Ken and his team clearly demonstrate that you can!
 
In ICU if we have a critically ill patient that has active life threatening bleeding then we immediately request consultant level support from all relevant specialities, we don't haplessly struggle on for hour after hour until it is too late.
 
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 <mgreeds at reeds.uk.com>
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 <mgreeds at reeds.uk.com> 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.