Mission: Healing December 12, 2011

PGY 39, Day 164

Ask the survivor?

It has been know for decades that patients can't survive after traumatic cardiac arrest "in the field" despite the best of care. In other words, if you have an accident or significant injury from any cause, if it is severe enough to cause your heart to stop, and to require cardiopulmonary resuscitation, you are probably dead. And, then there are the exceptions ... the occasional patient who survives, despite the fact that they "should have been dead."

Recently, an article published in one of our medical journals looked at the cost and outcome of treating patients who "should die" as a result of their trauma.

http://www.ncbi.nlm.nih.gov/m/pubmed/21986740/

According to this study, which involved the authors examination of trauma patients' CHARTS retrospectively (after the care was given), of the 294 trauma patients who should have died, only one survived despite treatment (0.3%) and required "long term care". The TOTAL cost of treating these patients was stated to be $3,852,446.65, or $13,103.50 per patient. They considered treatment of these patients to be a "violation" of guidelines and conclude that "no loss of neurologically intact survivors would have resulted had strict adherence to the guidelines been maintained."

Wow ... pretty harsh and rigid conclusions, but are they correct? Not so fast!

Here are my recommendations:

1. Ask the survivor! What is his or her current status?
2. Examine all trauma registries with regard to similar data?
3. Examine all survivors who "should have died" and see how they differ from the group at large?
4. Do a prospective randomized trial?
5. Examine the details of each case identified in the study and determine weather or not any of the care provided could have been improved?
6. What else? I always forget something. Please comment

Medical care should not be wasted on dead patients, but it is precision early care that dictates survival. How many patients were saved and are doing well, because VERY AGGRESSIVE CARE was provided in the field? Scoop and run is probably the best once an airway is established. Despite this "study" my opinion stands: When in doubt, err on the side of life & when you are dead, you are dead. So ... the problem remains ... how to determine death ... and especially how to determine who of the critically injured will die despite the best of care? In the meantime ... until we can answer these questions properly, err on the side of life, so people who have the potential to survive and live a good life don't die unnecessarily.

StepWisely(R) and have a nice day!

Dr. Mike