A 25 year old man is involved in some sort of violent, non-productive interpersonal relationship. He sustains a stab to the left chest, and is brought to your trauma center as a trauma team activation. During the FAST exam, a moderate effusion with visible clot is seen in the pericardium.
Appropriately, you run to the OR and prepare for a left thoracotomy. You perform a pledgeted repair of the ventricle and close. The patient does well and is discharged home five days later. He returns to your clinic the following week and is doing well. You remove the staples.
One week later, he returns to your emergency department complaining of significant chest pain. He describes it as deep, behind his sternum, and it seems to be exacerbated by breathing.
Now what? What are you thinking about? What additional exam do you need. What labs?
Tweet or comment with your answers and suggestions. More on Monday!
With the implementation of resident work hour restrictions more than 10 years ago, resident participation in clinical care has declined. In order to make up for this loss of clinical manpower and expertise, many hospitals have added advanced clinical providers (ACPs, nurse practitioners and physician assistants). These ACPs are being given more and more advanced responsibilities, in all clinical settings. This includes performing invasive procedures on critically ill patients.
A recent study from Carolinas Medical Center in Charlotte NC compared complication rates for invasive procedures performed by ACPs vs residents in a Level I trauma center setting.
A one year retrospective study was carried out. Here are the factoids:
Residents were either surgery or emergency medicine PGY2s
ACPs and residents underwent an orientation and animal- or simulation-based training in procedures
All procedures were supervised by an attending physician
Arterial lines, central venous lines, chest tubes, percutaneous endoscopic gastrostomy, tracheostomy, and broncho-alveolar lavage performances were studied
Residents performed 1020 procedures and had 21 complications (2%)
ACPs performed 555 procedures and had 11 complications (2%)
ICU and hospital length of stay, and mortality rates were no different between the groups
Bottom line: Resident and ACP performance of invasive procedures is comparable. As residents become less available for these procedures, ACPs can (and will) be hired to take their place. Although this is great news for hospitals that need manpower to assist their surgeons and emergency physicians, it should be another wakeup call for training programs and educators to show that resident education will continue to degrade.
Reference: Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma 77(1):143-147, 2014.
Several decades ago I took care of a patient who posed an interesting challenge. He had been involved in an industrial explosion and had sustained severe trauma to his face. Although he was able to speak and breathe, he had a moderate amount of bleeding and was having some trouble keeping his airway clear.
Everyone frets about getting an airway in patients who have severe facial trauma. However, I find it’s usually easier because the bones and soft tissue move out of your way. Or are already gone. As long as you can keep ahead of the bleeding to see your landmarks, things will go fine.
In this case, the intubation was easy. The epiglottis was visible while standing above the patient’s head, so a laryngoscope was practically unnecessary! But now, how do we secure the tube so it won’t fall out? Sure, there are tube-tamer type securing devices available, but what if they are not available to you? Or this happened in the field? Or their face was missing or falling off? Or it was in the 1980’s and it hadn’t been invented, like this case?
The answer is, create your own “skin” to secure the tube. Take a Kerlix-type stretchable gauze roll and wrap it tightly around their face, and their head if needed. Remember, they are sedated already and they can breathe through the tube. This also serves to further slow any bleeding from soft tissue. Once you have “mummified” the head with the gauze roll, tape the tube in place like you normally would, using the surface of the gauze as the “skin.”
Be generous with the tape, because the tube is your patient’s life-line. Now it’s time for the surgeons to surgically stabilize this airway, usually by converting to a tracheostomy.
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