Most trauma centers have at least a few practice guidelines to help the standardize the way they manage common injuries. Solid organ injury. Elder trauma. Chest tube management. But they are all designed for use in patients who present shortly after their injury.
What about someone who presents a day or two, or more, after their injury? That changes the picture entirely. Most guidelines have a time component built in. A TBI protocol requires a repeat head CT after a certain period of time. Solid organ injury patients may have restricted activity or frequent vital signs for a while.
But all too often, trauma professionals treat the patient with delayed presentation exactly the same as fresh trauma. For example, a patient falls and bumps their head. They have a persistent headache, and after two days decide to visit their local ED. The CT scan shows a small amount of subarachnoid blood in the area of the impact. Your practice guidelines says to admit for observation, frequent neruo checks, and repeat head CT in 12 hours.
Or a young male playing sports took a hit to his left flank. After 3 days, he’s just tired of the pain and comes to the ED for some pain medication. CT scan shows a grade III spleen injury with a small amount of hemoperitoneum. Your protocol says to admit, make NPO, liimit activity, and observe for 2 days.
What would I do in these cases? Think about it! If the patients had presented right after the event, they would have gone through your guideline and would have been discharged already. So I would review the images, talk to the patients about their injuries, then send them home from the ED with followup. They’ve already passed!
Bottom line: Remember, practice guidelines are not etched in stone. Variances are possible, but need to be well thought out in advance. And hopefully documented in the chart to expedite the inevitable trauma performance improvement inquiry. If the requisite amount of time has gone by, and the history and exam are reasonable, the patient has already passed your protocol. Send them home.
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.
Over the past two days, I’ve discussed a method for optimizing the hand-off process between prehospital providers and the trauma team. Besides improving the quality and completeness of information exchange, it also fosters a good relationship between the two. All too often, the medics feel that “the trauma team is not listening to me” if the procedure is to move the patient onto the ED bed as quickly as possible.
And they are right! As soon as the patient hits the table, the trauma team starts doing what they do so well. It’s impossible for humans to multi-task, even though they think they can (look at texting and driving). We switch contexts with our brain, from looking at the patient to listening to EMS, back and forth. And it takes a few extra seconds to switch from one to the other. Team members will not be able to concentrate on the potentially important details that are being relayed.
What should you do if the team doesn’t want to wait?
First, educate them. Except for those who are in extremis or arrest, the patient can wait on the EMS stretcher for 30 seconds. Nothing harmful is going to happen in that short period.
Then, create a hard stop. The easiest way to do this is to place a laminated copy of the timeout procedureon the ED bed. And the rule is that the card doesn’t move until the timeout is done. This is very similar to what happens in the OR. The process should take only 30 seconds, then it’s over and the team can start.
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!