Category Archives: Trauma Center

Trauma Center

When Should You Activate Your Backup Trauma Surgeon?

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The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

  • It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
  • It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail. 

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.

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Trauma Center

Trauma Activation Vs. Stroke Code

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Let’s look at an uncommon scenario that crops up from time to time. Most seasoned trauma professionals have seen this one a time or two:

An elderly male is driving on a sunny afternoon, and crashes his car into a highway divider at  25 miles per hour. EMS responds and notes that he has a few facial lacerations, is awake but confused. They note some possible facial asymmetry  and perhaps a bit of upper extremity weakness. No medical history is available. Witnesses state that he was driving erratically before he crashed. Medics call the receiving trauma center in advance to advise them that they have a stroke code.

Is this a reasonable request? Stroke centers pride themselves on the speed of their stroke teams in assessing, scanning, and when appropriate, administering thrombolytics to resolve the problem. But if there are suspicions of stroke in a trauma patient, which diagnosis wins? Trauma team or stroke team?

Lets analyze this a bit further, starting with diagnosis. Remember the first law of trauma:

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Could the symptoms that the paramedics are observing be due to the car crash? Absolutely! The patient could have a subdural or epidural hematoma that is compressing a cranial nerve. There might be a central cord injury causing the arm weakness. His TBI might be the source of his confusion. The facial asymmetry could be due to a pre-existing Bell’s palsy, or he could have had a stroke years ago from which he has only partially recovered.

If the stroke team is called for the patient, they will focus on the neuro exam and the brain. They will not think about trauma. They will follow the patient to CT scan looking for the thing that they do best with. If they don’t see it, the patient will return to the ED for (hopefully) a full trauma workup. If there are occult injuries in the abdomen, then the patient may have been bleeding for an hour by then. This elderly patient will then be way behind the eight ball.

And let me pose the worst case scenario. The patient is taken to CT by the stroke team, and lo and behold he has a thrombotic stroke!  This patient had a stroke, which caused him to lose control of his car and explains most of his findings. Again, the stroke team will do what they are trained to do and give a thrombolytic. They are still not thinking about trauma. Within minutes the patient becomes hypotensive and his abdomen appears a bit more distended. He is rushed back to the ED (remember, no CT in hypotensive patients even if you are in the scanner) and a FAST exam is very positive for free fluid throughout the abdomen. Imagine the look you will get from the surgeon as they run to the OR to perform a splenectomy on this fully anticoagulated patient!

Bottom line: Starting a patient encounter with the wrong type of activation can cause major problems. The most common problem is anchoring bias. When a stroke code is called, everyone focuses on the neurologic change that triggered the call. And they stop looking for other things that might call it into question. For example, they might be so intent in calling neurology and getting the patient to CT that they miss the bloody laceration on the back of the scalp.

If you have a patient who is trauma vs stroke, trauma always wins! Remember the first law and try to find traumatic reasons for all signs and symptoms. Perform your standard trauma workup and incorporate the appropriate head scans into your evaluation. Then and only then should the stroke team be called.

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Trauma Center

Adolescent Experience At Pediatric vs Adult Trauma Centers

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A number of papers have addressed the clinical differences between adult trauma centers that provide care for children and pediatric trauma centers. For example, differences in TBI outcomes and solid organ injury management have been noted, to name a few. But I’ve seen very little written on the patient (and parent) experiences at these centers.

Adolescents exist between the adult and pediatric worlds. They frequently suffer injury from adult mechanisms like car crashes, interpersonal violence, and drugs/alcohol. But they are still developing from anatomic, physiologic, and psychosocial standpoints. So which trauma center is better for them? An adult center with more experience managing their injuries, or a pediatric center more attuned to their distinct psychosocial needs?

The surgery group at the University of Calgary in Alberta, Canada, performed a prospective, 1.5 year study of adolescents (aged 15-17) and their caregivers when admitted to the local adult or pediatric trauma center. Enrollees received a survey eight weeks after discharge to glean details of their experience. This survey was a validated tool called the QTTAC-PREM ( Quality of Teen Trauma Care Patient Reported Experience Measure).

This survey was very comprehensive and clocked in at 31 pages in length! It included questions on visits by friends, interactions with hospital staff, schoolwork, pain control, mental health, privacy, and follow-up visits.

Here are the factoids:

  •  A total of 90 patients were enrolled; 51 were admitted to pediatric trauma centers and 39 to adult centers
  • Survey completion rates were reasonable, with 77 returned in the pediatric center group and 41 in the adult center group (surveys could be completed by the patient, their caregiver, or both)
  • Patients taken to the adult center were more seriously injured (56% with ISS>9 vs. 10%)
  • Overall, there were few differences in experience, but parents gave lower ratings for communication, follow-up care, and the overall hospital score
  • The adult trauma centers had poorer family accommodations, as noted by both the patients and their parents

Bottom line: This is a (somewhat) interesting study looking beyond the purely clinical differences in adult vs. pediatric trauma centers. It has some significant problems, although it is still possible to derive some valuable information. 

First, it was a survey. And a 31-page survey at that! I throw most one-page surveys I receive away without a thought. So the enrollment and return rates are guaranteed to be low. Next, it was performed during the height of COVID, which changed everything. Fewer patients presented to the hospitals, and measures were in place, making them less friendly and accessible for patients and their caregivers. This could significantly alter any opinions of patient/parent experiences.

And finally, there are only two trauma centers in Calgary, one adult and one pediatric. So this study cannot be generalized easily to other centers in Canada or anywhere else in the world. In many ways, they are unique. So the actionable information contained in it is very limited. 

However, we can learn something. Communication is always an issue in hospitals. Pediatric centers are very familiar with dealing with parents, and adult centers would benefit by taking this page from their playbooks. Similarly, pediatric centers routinely provide housing for the parents, while adult centers have never had to prioritize this. 

A related question needs to be addressed: what about dual centers? That is, a combined Level I adult and Level I pediatric center. These hybrids are largely ignored, although they are more common in larger metropolitan areas. 

Regardless, ALL trauma centers can benefit from improved communication with their patients and accommodations for parents of pediatric patients.

Reference: Between Paradigms: Comparing experiences for adolescents treated at pediatric and adult trauma centres. Injury, published ahead of print, April 12, 2023.

If you are interested in the QTTAC-PREM questionnaire used in this study, you can find it in the supplemental data for this study:

Yeung M, Hagel BE, Bobrovitz N, Stelfox TH, Yanchar NL. Development of the quality of teen trauma acute care patient and parent-reported experience measure. BMC Res Notes. 2022 Sep 23;15(1):304. doi: 10.1186/s13104-022-06194-x. PMID: 36138467; PMCID: PMC9503226.

If you need help obtaining a copy, please feel free to email me.

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Trauma Center

Trauma Transfers Discharged From The ED

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Aren’t these embarrassing? A referring center sends you a patient with the idea that they will be evaluated and admitted to your hospital. But it doesn’t work out that way. The patient is seen, possibly by a surgical specialist, bandaged up, and then sent home. Probably to one that is quite a few miles away. Not only is this a nuisance for the patient and an embarrassment for the sending center, it may use resources at the trauma center that are already tight.

Transfer patients who are seen and discharged are another form of “ultimate overtriage.” In this case, the incorrect triage takes place at the outside hospital.  The trauma group in Oklahoma City reviewed their experience with these patients over a two year period. They looked exclusively at patients who were transferred in to a Level I center and then discharged.

Here are the factoids:

  • A total of 2,350 patients were transferred in, and 27% were transferred home directly from the trauma bay (!)
  • The three most common culprits by injury pattern were face (51%), hand (31%), isolated ortho injury (9%)
  • A third of these patients required a bedside procedure, including laceration repair (53%), eye exam (24%), splinting (18%), and joint reduction (5%)
  • Ten facilities accounted for 40% of the transfers

The authors concluded that the typical injuries prompting transfer are predictable. It may be possible to reduce the number of transfers by deploying telemedicine systems to push evaluations out to the referring hospitals.

Bottom line: This is quite interesting. Anyone who works in a Level I or II center is aware of this phenomenon. This abstract went a step further and quantified the specific issues involved. This center ended up discharging over 300 patients per year after transfer in. This is a tremendous drain on resources by patients who did not truly have the need for them.

The authors speculate that telemedicine evaluation may help reduce some of those transfers. This seems like an easy solution. However, it also poses a lot of issues in terms of who will actually staff the calls and how will they be compensated for their time.

There are a number of important take-aways from this abstract:

  1. Know your referring hospitals. In this study, there were 10 hospitals that generated an oversize number of referrals. Those are the targets / low hanging fruit. Identify them!
  2. Understand what their needs are. Are they frequently having issues with simple ortho injuries? Eye exams? This is what they need!
  3. Provide education and training to make them more comfortable. This allows you to target those hospitals with exactly the material they need and hopefully make them more self-sufficient.

This allows the higher level centers to reserve phone and/or telemedicine consultation for only the most ambiguous cases. It’s a better use of telehealth resources that may be needed, typically at night and on weekends.

Reference: Trauma transfers discharged from the emergency department-Is there a role for telemedicine? J Trauma Acute Care Surg. 2022 Apr 1;92(4):656-663. 

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Nursing, Trauma Center

Paying Respect After A Terminal Trauma Activation

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As all trauma professionals know, traumatic injuries are a major cause of death across all age groups. Well-trained trauma teams use all their skills to attempt to save critically injured patients. But, unfortunately, there are occasions in which they die despite all our efforts. In most of these cases, the time of death is called, and team members then peel off their protective clothing and melt away to pursue their usual duties.

These terminal trauma activations are mentally challenging as the proper interventions are ordered and carried out. They are also physically demanding, especially when heroic measures such as CPR are needed. But one often-neglected issue is the emotional challenge. Every team member is invested in saving that person. Frequently, they can visualize their own spouse, parent, or child in place of the patient, and go all out to try to save them.

When these trauma activations are over, team members frequently do not have an opportunity to resolve their own emotional turmoil or achieve closure for the turmoil of the previous 30 minutes.

A recent paper from the Gunderson Health System in La Crosse, Wisconsin, studied a practice that seeks to achieve this closure and recognize the life of the deceased patient. They call this the PAUSE, an acronym for Promoting Acknowledgment, Unity, and Sympathy at the End of life.

This process was implemented about five years ago, and a multidisciplinary team from a variety of religious backgrounds and beliefs carefully worded the script. It works like this:

  1. The team leader calls the time of death.
  2. Team leader then states, “At this time, we would like to take a moment to honor the patient and staff.”
  3. A chaplain takes over and does the following:
    • (Chaplain states) For those who would like to stay,
      we’ll take a moment of silence to acknowledge this
      person, their death, and our care for them …
    • (Moment of silence—10 s)
    • (Blessing)
      We give thanks for ___(Name), those they loved, and
      those who loved them.
      We give thanks for the privilege of caring for them.
      We give thanks for our caring team.
      We ask that all may be whole and find peace. Amen.
    • (Chaplain states) Thank you for your care—for those
      who would like to stay, please do, for those moving
      on to other duties, Thank You.
  4. The team disperses.

The research group circulated a pre-implementation questionnaire and then sent a post-implementation questionnaire two years later. The questionnaires were the same, except six additional questions regarding experience with PAUSE were added to the post-survey.

Here are the factoids:

  •  There were 466 participants in this study; the number of patients treated was not stated
  • Participation rates were typical of questionnaire studies (40% pre-surveys and 23% post-surveys)
  • While not statistically significant, many team members reported improvements in internal conflict, feelings of emptiness, resilience, and ability to move on to the next task

Note the higher slightly and significantly improved feelings in the post-study. This chart was based on 57 respondents.

The authors concluded that the PAUSE process was a meaningful way to help trauma team members emotionally.

Bottom line: Studies like this are difficult to conduct and even more challenging to apply rigorous statistical methods. They frequently do not have statistically significant results. But one can see specific improvements despite the soft numbers. 

Many hospitals have some processes for terminal trauma activations. Most are not as well-scripted as this. But having been involved in them myself, I find it very helpful and comforting. I recommend all centers consider implementing something similar. Like most practice guidelines, this one is only suitable for adoption with adaptation. When adopting this, it is essential to work with your chaplains and recognize the specific ethnic and religious representation in your trauma center.

Reference: Trauma and Death in the Emergency Department: A Time to PAUSE (Promoting Acknowledgment, Unity, and Sympathy at the End of Life). J Trauma Nursing 29(6):291-297, 2022.

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