Ординатура / Офтальмология / Учебные материалы / Ocular Traumatology Springer

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  1.8  Strategic Thinking in Ocular

Traumatology

Ferenc Kuhn

1.8.1Introduction

What does a car driver do when given the task of driving from home to an unknown destination through unknown territory?

He consults a map, various “driving directions” Internet services, seeks advice from people who already drove between those two endpoints, or may even purchase a Global Positioning System device. One thing he certainly will not do is start the journey without planning. Getting lost can get the driver into trouble ranging from the inconvenient to the dangerous.

If a pilot needs a plan of how to drive from point A to point B, should not an ophthalmologist treating a patient with a serious injury also design a management plan first? This chapter discusses the elements of a systematic thought process. This planning has two levels: the strategy and the tactics.

•Strategy involves the grand plan such as indication for or against surgery, timing, type of intervention, and completeness (vs staging) of the surgery. Strategy can be further stratified (Table 1.8.1).

•Tactics involve dealing with individual pathologies and tissues.

Just as drivers need specific directions, in addition to a general map, for a specific trip, there is no single blueprint the ophthalmologist can apply for

This chapter addresses the strategic issues; the tactics are discussed in Sections 2 through 4.

Indeed, all trips are unique and must have a specific plan developed solely for that trip, but use of a general map is necessary to be able to design that specific plan.

80 Ferenc Kuhn

Table 1.8.1  The different components of surgical planning to treat the patient with a serious eye injury

Many of these questions also need to be addressed during counseling (see Chap. 1.4)

aDetails are provided in Table 1.8.3

each injury. There are no two trauma cases absolutely alike; therefore, all need an individualized treatment plan. Based on the basic building blocks of strategic thinking, the ophthalmologist can develop his own approach to the management of eyes with serious trauma.

A severely injured eye is often a “surprise package” : the surgeon may not know all tissue lesions that have occurred or to what extent, how the injury to one tissue effects the behavior and thus treatment of another, and what problems he will face that he has never experienced before. Nevertheless, a comprehensive management plan should be designed before actual treatment is initiated. Conversely, this plan should never be “written in stone”: it must be changed according to patient requests (see Chap. 1.4), specific preor intraoperative findings, and from noticing how tissues react to his maneuvers. This chapter is dedicated to issues that reflect strategy or general thinking (“what, when, why”), not to tactics such as dealing with specific tissue conditions (“how”); these are found in the appropriate chapters in this book (Table 1.8.2).

ZPearl

A car driver must know where he is and where he needs to go; he can then figure out how to get there. Similarly, an ocular traumatologist must know the condition of the eye and to what extent the normal anatomy can be restored; a plan must be designed as to how this reconstruction can be achieved.

This plan, however, is based on a knowledge of the general rules, on possessing extensive knowledge of the elements of strategic thinking.

A very appropriate term coined in this context by R. Morris, Birmingham, Alabama.

One example: A healthy retina is able to withstand much more surgical trauma than one in a patient with advanced diabetes. Peeling of PVR membranes is therefore done very differently in eyes with unhealthy retina.

To use the driver example: This chapter discusses the need for using maps, how to select the map, and what the rules of choosing the roads to be driven are.

Actual driving of the car (when and how to steer or shift, use the turning signal, etc.: this, in our example, is on the same level as the tissue tactics chapters.

Fig. 1.8.1  The need for systemic triaging in people injured by a blast.1 a While injury to the left is eye is obvious and to the right eye likely, management of the visible brain damage obviously must take precedence. b The patient also has chest injuries: the general surgeon and the ophthalmologist must discuss which of them should treat the patient first (Photographs courtesy of D. Kalra, Panchkula, India)

1  Caused by IED (improvised explosive device), planted by terrorists and exploded by remote control. The IEDs are packed with metal splinters, ball bearings, and nails to increase the carnage.