All posts for the month August, 2012

The right thing to do with trauma patients that come in arrest, or near arrest can be difficult to figure out. The generally accepted, evidence based rule for this is that for victims of penetrating trauma, they must have had vital signs when EMS arrived (found dead, stays dead), and should not have been in full arrest for more than ~10 minutes (with CPR). For blunt, the patient must have had vital signs of some sort (a pulse at least) in the ED, or within a minute or two of the ED. Even with loss of vital signs at the entrance to the ED, the recovery to discharge rate is abysmally low.

But, EMS often breaks their backs with these patients, doing rapid extrication, ALS, CPR, and priority red transport, and it always feels wrong to just pronounce them on arrival when we stop CPR and find no pulse and fixed dilated pupils. I hate to admit it, but I have done resuscitative thoracotomies in these patients, when I know very well there is no chance of survival. Often, making sure the airway is in, putting in bilateral chest tubes, and a shot of Epi is enough to make everyone feel we’ve tried in the bay, but it’s really just going through the motions, since none of that will resuscitate a trauma patient that has bled out.

I think its important for all trauma surgery, ED, and EMS providers to know the real stats on trauma arrest. I believe the highest discharge from hospital alive rate in penetrating was 7% when arriving in full arrest (some studies are higher, but if you read those carefully, a number of patients were not in arrest, but were just hypotensive), and I have never seen a discharge from hospital rate for blunt arrest over 1%. We have had discharge alive in blunt patients who arrested in the ED, but these patients arrived with vital signs, and lost them in the ED in front of us, making return of circulation and aortic clamping almost immediate. Even with that, the vast number of patients with trauma who have arrested in front of me do not survive.

To make the right decision, you need to know the data.


Atul Gawande’s article asking why Cheesecake factory can provide outstanding products in diverse environments, at reasonable prices, and why we cant do this in hospitals has been sent to me by 5 people. The theme is “why cant we do this?”. I have several comments:

First, I respect Gawande tremendously, but there is a big knowledge gap between doctors who practice medicine, and doctors who attempt to control the way other doctors practice medicine. Gawande is in the former group, and I am in the latter. It is easy to identify the problems in medicine, but much harder to devise and implement solutions.

Second, the line cooks, waitresses, managers, and other employees at Cheesecake Factory accept their positions knowing they are joining an enterprise where their individual initiative is neither wanted, nor needed. I am fairly certain Cheesecake Factory isn’t looking to hire Thomas Keller as a chef. They want people that will easily fit into a system. They are rapidly indoctrinated to a system of processes that have already been figured out. Since, the processes are known and vetted, they are relatively easy to implement in individual restaurants, and in restaurants in different states, or countries. In addition, they have concrete data to represent their success and failure. Sales drops are easy to identify, as well as products that don’t sell, entrees with excessive production costs, and ingredients with high acquisition costs. This data can be operationalized immediately, without argument. That allows the restaurant to be nimble in response to market forces. In medicine, we have few if any vetted and conclusively proven care processes. Sometimes I wonder if there is anything we do that we can definitely say is the “best” way to do it. You only need to look at appendectomy (laparoscopic versus open), CPR (ABC now is CAB), angiography for vascular disease, CABG versus angiography, etc., etc., etc. Sometimes the lack of definitive data for so many things leads to the creation of care guidelines that turn out to be flat wrong, when new studies emerge. At Cheesecake Factory, if they sell a lot of something with a high margin, its awesome, if they dont, they stop making it. We dont have that option.

And finally, Doctors. We are all people at the top of our classes most of our lives, and then went into a profession where we were taught the ultimate responsibility for any adverse outcome was our fault, not the fault of the system. We question and object to data, refuse to follow guidelines because there “might” be a patient that would come along that would be hurt by the guideline, and don’t accept that there are some parts of medical care that others (NPs and PAs) do just as well as we do, if not better. Nevermind, the cottage industry nature of each medical practice where you are responsible for generating income to support you and your family. The more work you do, the higher your income (in general). A manager or chef at Cheesecake Factory does not possess these attitudes, or if they do, I am fairly certain they do not have the power to run their line or restaurant however they see fit. Doctors can, in general, run their clinical practice with a great deal of latitude.

Pointing out how far we have to go in medicine is no longer helpful. Anyone who doesnt realize that change is necessary has been asleep for the past 10 years. We need solutions that take into account the nature of medical care in it’s true state. Success in changing and controlling medical practice occurs when all involved realize they need to find a path that decreases variability, costs, and adverse outcomes.  First you need to identify care processes that are optimal (given the current state of knowledge), then you need to have information and control systems that make it easy for practitioners to comply with the recommended care processes, you need to provide feedback as close to real time as possible, and then you need to constantly look at your outcomes to make sure you are not hurting anyone. It’s a tall order, but it requires everyone to be on the same page.

A discussion of the tension between cost containment and the need to prevent unexpected negative outcomes. Some patients do not have a sign on them saying “I’m sick, intubate me and take me to the ICU”. Sometimes the signs are much more subtle, and will not be appreciated without a high degree of suspicion and paranoia.