Category Archives: General

But The Radiologist Made Me Do It!

The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?

  1. … recommend clinical correlation
  2. … correlation with CT may be of value
  3. … recommend delayed CT imaging through the area
  4. … may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
  • Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
  • Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
Related post: 

Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.

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Surgeons Who Operate Post-Call

Fatigue is a big deal for trauma professionals. I previously devoted a week of posts to detailing research on fatigue, and dedicated the June 2012 Trauma MedEd newsletter to the topic. So I just reviewed a paper suggesting that it might not be such a big deal for attending (consultant) surgeons who operate after they’ve been on call.

The whole idea came about because residents in the US (registrars) have had restrictions to their work hours in place for 10 years, limiting them to only 80 hours per week. Yet the attending physicians, who are older and more likely to show the effects of fatigue, have no such limits. They can work as long as they want. Maybe their greater experience or long-established habits of occasional sleep deprivation are protective?

The group in Memphis looked at this phenomenon, performing a retrospective review of patients operated on by surgeons post-call and those who were not. They looked at 737 patients over 3.5 years, of which 15% were performed by post-call staff surgeons. Here are the key points:

  • Only cholecystectomy, hernia and intestinal procedures for bowel obstruction, ischemia or bleeding were evaluated
  • The authors used complications and readmission as outcomes to monitor
  • Complications occurred in about 13% of both post-call and no-call groups. No difference.
  • Readmissions within 30 days occurred in about % of both groups. Again, no difference.

So it looks like it’s okay to operate after the surgeon’s been up at night, right? Wrong! This is another perfect example of why it’s so important to read the whole paper, not just the abstract. Major problems:

  • The actual amount of sleep or fatigue levels are not quantified, so it’s a mix.
  • It’s a teaching hospital, so the surgeons always operate with a trainee at some level. The residents either do the work, or can “double check” the surgeon’s work to prevent any significant errors.
  • Complications and readmission rates are very crude indicators of error. Only the most egregious problems would manifest as one of these.

Bottom line: There is plenty of non-medical literature out there that shows that fatigue is bad (aviation, trucking, marine operations). And as much as we’d like to believe it, surgeons and other physicians are in no way immune to its effects. What this paper really showed is that if you are supervising a well-rested trainee and looking at outcomes that aren’t directly related to fatigue, everything looks great! It’s not, and all trauma professionals need to be aware of the fact that, even though they feel invincible and that they can do anything after sleep deprivation, it’s just their fatigue talking. Protect your patients and make sure that everyone who takes care of them is in tip-top shape.

Reference: Outcomes of operations performed by attending physicians after overnight trauma shifts. Journal Am Coll Surg, in press 11 Jan 2013.

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CIWA Demystified

What exactly is the CIWA protocol?

It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.

The Clinical Institute Withdrawal Assessment measures 10 items that are association withdrawal:

  • Nausea / vomiting
  • Anxiety
  • Paroxysmal sweats
  • Tactile disturbances (itching, bugs crawling on skin, etc)
  • Visual disturbances
  • Tremors
  • Agitation
  • Orientation
  • Auditory disturbances
  • Headache

All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.

The total score is used to determine whether benzodiazepines should given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.

The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.

For a copy of the CIWA scoring criteria, click here.

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EMS Spine Precautions And Use Of The Long Backboard

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma have just released a position statement clarifying the use of spine precautions and backboards in trauma patients. Backboards have been used since forever in preparing to move injured patients to hospitals. Unfortunately there are several problems:

  • The benefits of backboard use has never really been shown
  • Backboards can cause more injury, including pain, agitation, and skin breakdown
  • The risks vs benefits of using a backboard are seldom considered

So the following recommendations have been made:

  • Appropriate patients for backboard use include those with blunt trauma and altered consciousness, spine pain / tenderness / deformity, neurologic deficit
  • Additional patients who might benefit include those with a high energy mechanism and intoxication, inability to communicate, or distracting injury. Note that these leave a lot to the imagination!
  • Patients with penetrating injury to head, neck or torso without neurologic deficit do not need a backboard
  • Rigid cervical collar alone is sufficient in most patients who are ambulatory at the scene, will undergo a long transport time, or for whom a backboard is not otherwise indicated (see next bullet)
  • Backboard is not necessary in patients who meet all the following criteria: GCS 15, no spine tenderness or abnormality, no neurologic deficits, no distracting injury and not intoxicated
  • Even if a backboard is not necessary, EMS personnel should always be aware of other spine precautions, including a collar, securing the stretcher, minimizing patient movement, and maintaining inline stabilization when needed
  • The backboard should be removed as soon as practical in the ED

Related posts:

Reference: EMS spinal precautions and the use of the long backboard. Prehosp Emerg Care ePub March 4, 2013.

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Jehovah’s Witnesses And Blood Transfusion Demystified

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encounted in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses beleive that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

  • Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
  • Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
  • Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availabilty of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
  • Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
  • Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
  • Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
  • Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

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