Trauma call coverage is not always easy to come by, especially at lower level trauma centers and in rural areas. Many centers come to rely on locum tenens surgeons to fill gaps in their call schedules. Unfortunately, this can create some headaches.
There is currently no trauma literature on this topic. Other disciplines, most recently pediatric surgery, have some published suggestions (I hesitate to call them guidelines) on requirements and expectations based on the ACGME core competencies.
Here are some of the nuances that any trauma program needs to recognize if the use of locum tenens surgeons is being considered:
- Board certification – This is a basic tenet of trauma center verification and should be absolutely required
- Trauma CME – Make sure that all locums meet the CME or internal education program (IEP) requirement before they start
- Core vs non-core surgeon – Locums are best designated a non-core surgeon so they are not required to attend multidisciplinary PI committee meetings (MDPI)
- Dissemination of committee proceedings – Make sure that this is well-documented. Since these surgeons are not required to attend MDPI if they are non-core, they must be aware of all items discussed, particularly if it involves their care
- Responsibility for quality issues – This is the most troubling aspect of using locums. It’s tough to hold one of these surgeons responsible for issues arising from their care if they have left and are never coming back. Make sure there is a mechanism to send feedback about their care even after they are gone for good. And document it well!
Bottom line: In my opinion, the use of locum tenens to cover trauma call gaps is a necessary evil. It should only be used until a more stable coverage pool is available. The management of quality issues in particular is much more difficult when using roving surgeons. If you must use them, use them wisely and only briefly.
Reference: Proposed standards for use of locum tenens coverage in pediatric surgery practices. J Pediatric Surg 48:700-703, 2013 (letter).
I’ve written previously about how often imaging gets repeated once a trauma patient gets transferred to a trauma center (click here). There are many reasons, including clinical indications, need for advanced imaging (reconstructions), or lack of contrast. But at least 20% have to be repeated because the media is incompatible or not sent with the patient. Sounds like a problem, but is it a significant one?
A recent retrospective analysis of about 2,000 transfers to a Level I center looked at the reasons for repeat imaging and changes in outcome due to it. The paper found several interesting things:
- Repeat imaging was more likely in more severely injured patients
- Hospitals that transferred more patients to the trauma center tended to do more scans before transfer
- Patients who had repeat imaging stayed in the ED longer waiting for definitive disposition
- Repeat images did not improve outcomes (LOS, DC home, mortality)
- A rough estimate of $354 more in charges was attributed to repeat imaging
Bottom line: Repeat imaging is wasteful, expensive and increases time in the ED. And don’t forget about the radiation exposure. With all the emphasis on pushing hospitals to use an electronic medical record, there needs to be a similar push to standardize methods for transferring radiographic images between hospitals to address the problem of repeat imaging.
Reference: Repeat imaging in trauma transfers: A retrospective analysis of computed tomography scans repeated upon arrival to a Level I trauma center. J Trauma 72(5):1255-1262, 2012.
Yesterday, I wrote about our algorithm for clearing the cervical spine in an adult with normal mental status. Today, I’ll go over our protocol for obtunded patients. You can download it using the link below.
Here are the key points:
- MRI is the cornerstone of definitive evaluation of the ligaments once a normal CT spine study has been obtained
- There is no time limit for getting the MRI
- Spondylosis or degenerative changes are a red flag if MRI is not possible; the spine service must always be involved if either of these are present
My center is in the process of updating our cervical spine clearance protocols, and I wanted to share this work with you to help those who may be doing the same. Today, I’ll review our new clearance method for patients with normal mental status. Tomorrow I’ll go over the protocol for patients who are obtunded.
Here are the key points:
- Clinical clearance is acceptable except in patients with a high risk mechanism (see link to YouTube video below for clinical clearance technique)
- If risk factors are present or exam is abnormal, we use our Blunt Trauma Imaging Protocol to order the appropriate imaging study (see link below)
- If clearance efforts fail but radiographs are normal, upright plain images are obtained to evaluate stability
- Flexion/extension xrays are no longer used
- Patients with an abnormal exam but normal radiographs may be discharged with a soft collar and re-evaluated in a week.
Many of you know my opinion on soft collars (see link below). However, they do serve a purpose here. The protocol will demonstrate that if the patient potentially has an injury, it is stable. Unstable injuries will have been identified and referred to a spine specialist. The collar reminds the patient to voluntarily limit their neck motion to reasonable amounts until they are re-evaluated. And it is also inexpensive, does not lead to skin breakdown, and has much better patient compliance.
Yesterday, I wrote about the classic Gustilo and Anderson open fracture classification system. Today, I’ll explain the newer classification system proposed by the Orthopaedic Trauma Association (OTA).
The OTA developed this system using both good and not so good methodology: literature review and panel consensus. It offered an opportunity to refine definitions to try to make the system as useful as possible. It evaluates 5 pathoanatomic factors and provides 3 subgroupings for each factor. Here’s the rundown:
- Can be approximated
- Cannot be approximated
- No appreciable muscle necrosis, or some injury with function intact
- Loss of muscle but remains functional, or localized necrosis in injured area that requires excision
- Dead muscle, loss of function, partial or complete compartment excision, complete disruption of muscle-tendon unit, muscle injury not approximatable
- No injury
- Injury, no ischemia
- Injury with distal ischemia
- None or minimal
- Surface, easily removed and not embedded in deeper tissues
- a. embedded in bone or deep tissues, b. high risk environment (feces, contaminated water, etc.)
- Bone loss, but still some contact between proximal and distal fragments
- Segmental bone loss
The authors recommend using this classification at the end of the surgical debridement for best accuracy. It was also disigned for simplicity to reduce variability between raters.
Bottom line: Although it looks a bit clunky, this new OTA open fracture scoring system looks to be an improvement over the good old G&A. Expect to begin seeing research papers using this system in the near future. But it will take some time to build up the depth of experience with this system to be able to make good predictions on outcomes.
Reference: A new classification scheme for open fractures. J orthop Trauma 24(8):457-465, 2010.