[Kellam] If you have a pelvic fracture, and a patient's hypotensive, he's bleeding. Question. Next question is, where? And we'll get to that in one moment, but just so we get along with this, some questions have been asked, is there any way or any predictive value--we'll start off maybe with Chip--when you see these patients with a history mechanism, the fact is that maybe you put a binder on and they suddenly get better. Does that make you happy or is there any predictive value in anything you're doing with these noninvasive techniques in the history that guarantees you or can lead you into a different way of thinking or not? Or is it you're still moving with the same speed?
[Routt] Well, I think anytime someone gets better that's good. So I like it when someone gets better, and I think several of the points that have been made we need to amplify. The physical exam doesn't have to include destabilization of the clot--simply compressing or palpating the patient's pubic area, you'd feel a large defect unless it was just he was just a massive human, for whatever reason. So we don't have to disturb the clot to identify a defect in this zone. And I think if a patient responds to volume resuscitation or thermal regulation or a circumferential wrap, I don't think you have to buy devices. Everyone has a sheet in their hospital they can function quite well on, go back to beanbags, they're very readily available. I think if the patient responds to some form of circumferential sheet, I think it gives everyone a sense of relief but I think we're all aware of the--I think if you work long enough, hard enough, good enough --if you work enough, you know these patients can turn left quickly, or turn the way you don't want them to turn, depending on which country you're in. Maybe that was impolite--go the wrong way clinically. So I think everyone uses a little bit but, I think, not so much.
[Kellam] OK, Mike, is there any proof that any of these work yet? These noninvasive things?
[Routt] Is there clinical proof?
[Kellam] Well you don't have to answer that, clinical proof, I was going to ask Mike.
[Routt] I'm sorry.
[Kellam] You can add it though.
[Routt] There's certainly anecdotal proof.
[Bosse] Proof in the way that you want it, Jim, there's no proof that this works, that's all.
[Kellam] OK.
[Brohi] So this patient does get a sheet wrapped around him, and a towel clip you can see there and maybe supports Sal's claims--his pelvic fracture disappears to a certain extent, but Sal would still be worried.
[Routt] Can I make the point? A normal-looking pelvic x-ray does not mean a stable pelvis. And I think if all of you remember one thing today, from here, just because you have a fairly normal-looking pelvis and assembly of bones, that does not mean a stable pelvic ring.
[Kellam] OK. Before we move to the next stage there are a couple of questions that we'll take a couple of minutes and see if we can address.
[Mark Vrahas] Mark Vrahas, Boston. I wanted to rephrase Adam Starr's questions and get very specific answers from the panel because I think it's critical as Adam said, moving on to what we do in the next stages. I don't think there's any question the definition of shock--the patient's in shock if they have hypoperfusion and he certainly has indicators of hypoperfusion--even if he had just an elevated pulse he would have an indication of that. The question is, what category this pelvis falls in. When patients come in with pelvic fractures, I think, they come in three categories--there are the patients that have had the pelvic fracture and they've already stopped bleeding in the field. They may need further resuscitation to get them out of shock, but you can put a band-aid on their head, and they'll still stop bleeding.
[Kellam] Hurry up, Mark.
[Ferris] There's a second group of patients that come in and they're bleeding still but are going to stop no matter what you do, and there's a third group of patients that aren't going to stop. Is there anything you can do, base excess, pelvic x-ray, initial blood pressure, that tells you if that patient's going to go on to 30 units of blood loss or not?
[Kellam] Tom, yes or no?
[Scalea] No.
[Kellam] Sal, yes or no?
[Sclafani] I think most patients with pelvic fractures will not come, present like this. And those patients are unlikely to develop, in four hours, shock. The people with shock come in with shock and either stay in shock or come out of shock, but I don't think that most patients will do that. They may require transfusion--maybe they don't go into shock because we do angiography so quickly, I don't know.
[Kellam] OK. Mike--ah, sorry Mike--Andy--yes or no? Sal's taken half your time.
[Burgess] We don't know, to be honest.
[Kellam] No. Tim?
[Pohlemann] There's no way to know this. Especially in this case, he is late.
[Kellam] Mike?
[Bosse] No.
[Kellam] Chip?
[Routt] It's a good question, Mark. I'm going to pretend that they're all in your Vrahas Group 3, and I'm going to try to take a few to Group 1. And so I would like to attempt that everyone who we treat or we see, potentially can be your Group 3, and then we're going to try to get them to Group 1 as fast as we can, and then we can really sort of deal with it. So, predictive--perhaps not, but pretend we're going to treat them as Vrahas 3.
[Kellam] Thanks Chip, I tend to agree. Any other questions? OK, let's
move on.