Category Archives: General

General

The Fifth Law Of Trauma – Pediatric

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I knew there was a fifth law! Any time I give a pediatric talk, I mention it. This one applies to anyone who takes care of children, and is particularly important to EMS / prehospital providers and emergency physicians.

On occasion, medics are called to a home to treat a child in extremis, or occasionally in arrest. Similarly, extremely sick children are often brought to the ED by parents or other caregivers.

Here’s the fifth law:

A previously healthy child who is in arrest, or nearly so, is a victim of child abuse until proven otherwise.

Bottom line: It’s so easy to go down the sepsis path with sick kids, especially those who can’t talk yet. But healthy children tend to stay healthy, and don’t easily get sick to the point of physiologic collapse. If you encounter one as a prehospital provider, glance around at the environment, and evaluate the caregivers. In the ED, ask pointed questions about the circumstances and do a full body examination. What you hear and what you see may drastically alter how you evaluate the patient and may save their life.

Other Laws of Trauma:

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General

Prehospital To Trauma Team Handoff: A Solution

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I wrote about handoffs between EMS and the trauma team yesterday. It’s a problem at many hospitals. So what to do?

Let’s learn from our experience in the OR. Best practice in the operating room mandates a specific time out process that involves everyone in the OR. Each participant in the operation has to stop, identify the patient, state what the proposed procedure and location is, verify that the site is marked properly, and that they have carried out their own specific responsibilities (e.g. infused the antibiotic).

Some trauma centers have initiated a similar process for their trauma team as well. Here’s how it works:

  • The patient is rolled into the resuscitation room by EMS personnel, but remains on the stretcher.
  • Any urgent cares continue, such as ventilation.
  • The trauma team leader is identified and the EMS lead gives a brief report while everyone in the room listens. The report consists of only mechanism, all identified injuries, vital signs (including pupils and GCS), any treatments provided. This should take no more than 30 seconds.
  • An opportunity for questions to be asked and answered is presented
  • The patient is moved onto the hospital bed and evaluation and treatment proceed as usual.
  • EMS personnel provide any additional information to the scribe, and may be available to answer any additional questions for a brief period of time.

Bottom line: This is an excellent way to improve the relationship between prehospital and trauma team while improving patient care. It should help increase the amount of clinically relevant information exchanged between care providers. Obviously, there will be certain cases where such a clean process is not possible (e.g. CPR in progress). I recommend that all trauma programs consider implementing this “Trauma Activation Time Out For EMS” concept.

Tomorrow, I’ll share a best practice to make this process even better!

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General

The EMS Handoff: Opportunity for Improvement

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Handoffs occur in trauma care all the time. EMS hands the patient off to the trauma team. ED physicians hand off to each other at end of shift. They also hand off patients to the inpatient trauma service. Residents on the trauma service hand off to other residents at the end of their call shift. Attending surgeons hand off to each other as they change service or a call night ends. The same process also occurs with many of the other disciplines involved in patient care as well.

Every one of these handoffs is a potential problem. Our business is incredibly complicated, and given that dozens of details on dozens of patients need to be passed on, the opportunity for error is always present. And the fact that resident work hours are becoming more and more limited increases the need for handoffs and the number of potential errors.

Today, I’ll look at information transfer at the first handoff point, EMS to trauma team. Some literature has suggested that there are 16 specific prehospital data points that affect patient outcome and must be included in the EMS report. How good are we at making sure this happens?

An observational study was carried out at a US Level I trauma center with video recording capabilities in the resuscitation room. Video was reviewed to document the “transmission” part of the EMS report. Trauma chart documentation was also reviewed to see if the “reception” half of the process by the trauma team occurred as well.

A total of 96 handoffs were reviewed over a one year period. The maximum number of elements in the study was 1536 (96 patients x 16 data elements). The total number “transmitted” was 473, but only 329 of those were “received.” This is not quite as bad as it seems, since 483 points were judged as not applicable by the reviewers. However, this left 580 that were applicable but were not mentioned by EMS. Of the 16 key elements, the median number transmitted was 5, with a range of 1-9.

This sounds bad. However, the EMS professionals and the physicians have somewhat different objectives. EMS desperately wants to share what they know about the scene and the patient. The trauma team wants to start the evaluation process using their own eyes and hands. What to do?

Bottom line: EMS to trauma team handoffs are a problem for many hospitals. EMS has a lot of valuable information, and the trauma team wants to keep the patient alive. They are both immersed in their own world, working to do what they think is best for the patient. Unfortunately, they could do better if the just worked together a bit more.

Tomorrow I’ll share a solution to the EMS-trauma team handoff problem.

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Reference: Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care 13:280-285, 2009.

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General

How To Avoid Missed Injuries

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I’ve just spent two days here looking at the phenomenon of “delayed diagnosis” or missed injury. I believe that there are only two fundamental reason why this occurs:

  • Insufficient diagnostic technique – A good physical exam and/or specific diagnostic techniques were not performed. Or rarely, the injury cannot be readily detected by existing techniques and technology. The former is usually the real problem, and may be an issue with either the physical exam completeness and/or technique, or judgment used to obtain the appropriate diagnostic test. Example 1: a penetrating injury to the back is missed because the patient is not logrolled to examine this area. Example 2: a spine fracture is missed in an elderly patient with a fall from standing because the back pain found on physical exam is evaluated only with conventional imaging of the spine, not CT.
  • Failure to recognize the injury – The injury was actually identified on a test, but was not appreciated by the clinician. Example 1: the radiologist may not have appreciated and reported out a subtle anomaly in the cervical spine imaging. Example 2: you fail to check you patient’s lab tests and miss a sudden spike in serum amylase or lipase the day after your patient was kicked in the epigastrium by a horse.

So what can you do to avoid this potential problem? Here are some tips:

  • Admit that it can really happen to you. If the missed injury rate at your center is off the low end of the bell curve (< 5%) then you are either really good or really blind. You’d better take a close look at your performance improvement process, because you may be fooling yourself.
  • Adopt a firm definition of “delayed diagnosis.” Basically, you need a time frame after which a new diagnosis is considered “delayed.” It should be a reasonable time interval after the patient has left the ED. If it’s too short an interval (e.g. once they leave the ED), your number will be unnecessarily high. If it’s too long (days and days later), then significant morbidity may occur that you don’t account for. Most centers have adopted 24, 36, or 48 hours after patient arrival.
  • Implement a tertiary survey process. This is a complete physical re-examination followed by a review of all diagnostic studies (lab and radiology) that have been performed. This exam needs to be dated and timed to ensure that it is performed within the time frame noted above. If a new finding is discovered on the tertiary survey, it is not considered a delayed diagnosis. If found after the survey (or after the pre-determined time interval), it is and must be entered into your performance improvement process.
  • Be paranoid. I hate the phrase, “maintain a high index of suspicion” because it’s meaningless. It’s like those stupid “start seeing motorcycles” bumper stickers. You can’t see what you can’t see. But you can be suspicious all the time, constantly looking for the inevitable clinical surprises of trauma care. 

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General

Does The Tertiary Survey Really Work?

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Delayed diagnoses / missed injuries are with us to stay. The typical trauma activation is a fast-paced process, with lots of things going on at once. Trauma professionals are very good about doing a thorough exam and selecting pertinent diagnostic tests to seek out the obvious and not so obvious injuries.

But we will always miss a few. The incidence varies from 1% to about 40%, depending on who your read. Most of the time, they are subtle and have little clinical impact. But some are not so subtle, and some of the rare ones can be life-threatening.

The trauma tertiary survey has been around for at least 30 years, and is executed a little differently everywhere you go. But the concept is the same. Do another exam and check all the diagnostic tests after 24 to 48 hours to make sure you are not missing the obvious.

Does it actually work? There have been a few studies over the years that have tried to find the answer. A paper was published that used meta-analysis to figure this out. The authors defined two types of missed injury:

  • Type I – an injury that was missed during the initial evaluation but was detected by the tertiary survey.
  • Type II – an injury missed by both the initial exam and the tertiary survey

Here are the factoids:

  • Only 10 observational studies were identified, and only 3 were suitable for meta-analysis
  • The average Type I missed injury rate was 4.3%. The number tended to be lower in large studies and higher in small studies.
  • Only 1 study looked at the Type II missed injury rate – 1.5%
  • Three studies looked at the change in missed injury rates before and after implementation of a tertiary survey process. Type I increased from 3% to 7%, and Type II decreased from 2.4% to 1.5%, both highly significant.
  • 10% to 30% of missed injuries were significant enough to require operative management

Bottom line: In the complex dance of a trauma activation, injuries will be missed. The good news is that the tertiary survey does work at picking up many, but not all, of the “occult” injuries. And with proper attention to your patient, nearly all will be found by the time of discharge. Develop your process, adopt a form, and crush missed injuries!

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Reference: The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med 20:77, 2012.

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