Monthly Archives: March 2019

Equipment

Why Use A Hybrid OR For Trauma?

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Trauma is a surgical disease, and specifically, a disease of bleeding. So many of the tools and processes we have developed for its management revolves around the control of hemorrhage.

When a major trauma patient arrives in the resuscitation room, the initial management involves rapid assessment and correction of life-threatening conditions. Recognition of bleeding is paramount. A rapid decision must be made as to the source of hemorrhage and the best way to control it.

Traditionally, bleeding control has been relegated to the operating room. Body cavities are opened as appropriate, and exsanguination is controlled by clamping, repairing, and/or suturing.

However, some body regions are much more challenging. The most notable is the pelvis, and specifically, the unstable pelvis. In the old days, after wrapping or applying an external fixator, the best we could do was to ligate the internal iliac arteries bilaterally and hope the bleeding would slow down sufficiently (it never really stopped) so that internal packing might have a chance.

As the use of interventional radiography grew in trauma, it became possible to noninvasively occlude the internal iliacs. And then, the radiologists became skilled enough that they could selectively identify and embolize more distal bleeding vessels that would dramatically shut down pelvic bleeding.

But this introduced a conundrum. OR vs IR? Where to go after the trauma bay? I’ve long said that the only place an unstable trauma patient can go is to the OR. Not CT, and certainly not the radiology department.

Only the OR, because that’s the only place that something can actually be done about the bleeding. However, that’s not entirely true now.

Here’s the traditional algorithm for a patient with hemorrhage from pelvic fractures:

They go to the operating room OR interventional radiology. If they start in the operating room and can be stabilized (think external fixation and/or preperitoneal packing), then they might be able to be packaged and taken to IR for embolization. And likewise, if they were initially stable enough to go to IR but crash there, then they must immediately be taken to OR.

But what if you could do both in one room?! That’s the beauty of the hybrid room! It is entirely possible to do two, three, and maybe more cases on the same patient in the same room. Hence, the hybrid OR.

Tomorrow, is the hybrid OR for trauma useful?

Equipment

What Is A Hybrid OR, Exactly?

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A hybrid operating room is a special suite that allows advanced imaging to be carried out at the same time as one or more additional operative procedures. It’s that simple. It contains specialized imaging equipment including fluoroscopy and infusion equipment for radiographic dye administration. Some also contain CT and/or MRI capabilities, although the shielding required for these makes them very rare. It is generally stocked with a variety of endovascular

devices and supplies. The usual anesthesia circuits are available, as are selected surgical packs, typically related to vascular and CV surgery.

These suites are typically large, and can easily accommodate multiple operating teams. However, they are very expensive in a number of ways.

First, they take up a great deal of space. Many have the square footage of two or more standard operating rooms. Initial construction costs are very high, as are remodeling and maintenance costs. They can also tax the hospital engineering infrastructure, from electrical to plumbing to ventilation.

But if a hybrid room is available, it can deliver significant benefits to the hospital and to patient care. Intraoperative imaging can provide immediate quality assurance, and patients can undergo more complex procedures and enjoy a shorter length of stay.

Tomorrow, why use a hybrid room for trauma?

Equipment

It’s Hybrid OR Week!

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While quite a bit of trauma care is routine, involving simpler, single system injuries, a small subset of our patients sustains major, multi-system, and life-threatening ones. They require rapid access to skilled trauma professionals and advanced resources including imaging, operating rooms, and other procedures.

In most trauma centers, initial resuscitation takes place in a trauma resuscitation room in or near the ED. Some diagnostic imaging can be performed there, but more sophisticated studies may require a short (or longer) road trip. Operating rooms and other procedural areas are also usually more distant. And most importantly, each of these areas is designed for a single discipline. Diagnostic radiology has equipment, technicians, and radiologists available. Interventional radiology contains the specialized equipment needed for this more invasive procedure. ORs are designed specifically for surgical procedures, and frequently contain equipment for a single surgical discipline.

But some of our patients require it all! Think about a patient who arrives after a major car crash. Blood pressures are soft, the pelvis is grossly unstable, FAST exam is positive, and there is bleeding from the vagina.

How do we prioritize? Where do we go first? How long will it take the interventional radiology team to arrive? Where’s that external fixator equipment? Can we slip in a CT scan? Where’s OB/GYN??

The solution is right under our nose! Many hospitals have added so-called “hybrid ORs” to their operating suites in order to address the needs of their vascular and cardiovascular surgeons. This week I’ll cover everything you need to know about this important tool for trauma care. I’ll review:

  • What is a hybrid OR, exactly?
  • Why use a hybrid OR for trauma?
  • Is the hybrid OR for trauma useful?
  • Which patients may benefit from a hybrid OR?
  • So you want your own hybrid room?!

Tomorrow, what is a hybrid OR, exactly?

Philosophy

How To Tell If Research Is Crap

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I recently read a very interesting article on research, and found it to be very pertinent to the state of academic research today. It was published on Manager Mint, a site that considers itself to be “the most valuable business resource.” (?) But the message is very applicable to trauma professionals, medical professionals, and probably anyone else who engages in research pursuits. The link to the full article is listed at the end of this post.

1. Research is not good because it is true, but because it is interesting.

Interesting research doesn’t just restate what is already known. It creates or explores new territory. Don’t just read and believe existing dogma.

Critique it.

Question it. Then devise a way to see if it’s really true.

2. Good research is innovative.

Some of the best ideas come from combining ideas from various disciplines.

Some of the best research ideas are derived from applying concepts from totally unrelated fields to your own.

That’s why I read so many journals, blogs, and newsfeeds from many different fields. And even if you are not doing the research, a broad background can help you sort out and gain perspective as you read the works of others.

3. Good research is useful.

Yes, basic bench level research can potentially be helpful in understanding all the nuances of a particular biochemical or disease process.But a lot of the time, it just demonstrates relatively unimportant chemical or biological reactions. And only a very small number actually contribute to the big picture. For most of us working at a macro level, research that could actually change our practice or policies is really what we need.

4. The best research should be empirically derived.

It shouldn’t rely on complicated statistical models. If it does, it means that the effect being measured is very subtle, and potentially not clinically significant. There is a big difference between statistical and clinical relevance.

Reference: If You Can’t Answer “Yes” To These 5 Questions, Your Research Is Rubbish. Garrett Stone. Click here to view on Manager Mint.

Philosophy

Why Is So Much Published Research So Bad?

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Welcome to two days of rants about bad research!

I read lots of trauma-related articles every week. And as I browse through them, I often find studies that leave me wondering how they ever got published. And this is not a new phenomenon. Look at any journal a year ago. Five years ago. Twenty years ago. And even older. The research landscape is littered with their carcasses.

And on a related note, sit down with any serious clinical question in your field you want to answer. Do a deep dive with one of the major search engines and try to get an answer. Or better yet, let the professionals from the Cochrane Library or other organization do it for you. Invariably, you will find hints and pieces of the answer you seek. But never the completely usable solution you desire. 

Why is it so hard? Even with tens of thousands of articles being published every year?

Because there is no overarching plan! Individuals are forced to produce research as a condition of their employment. Or to assure career advancement. Or to get into medical school, or a “good” residency. And in the US, Level I trauma centers are required to publish at least 20 papers every three years to maintain their status. So there is tremendous pressure across all disciplines to publish something.

Unfortunately, that something is usually work that is easily conceived and quickly executed. A registry review, or some other type of retrospective study. They are easy to get approval for, take little time to complete and analyze, and have the potential to get published quickly.

But what this “publish or perish” mentality promotes is a random jumble of answers that we didn’t really need and can’t learn a thing from. There is no planning. There is no consideration of what questions we really need to answer. Just a random bunch of thoughts that are easy to get published but never get cited by anyone else.

Bottom line: How do we fix this? Not easily. Give every work a “quality score.” Instead of focusing on the quantity of publications, the “authorities” (tenure committees and the journal editors themselves) need to focus in on their quality. Extra credit should be given to multicenter trial involvement, prospective studies, and other higher quality projects. These will increase the quality score. The actual number of publications should not matter as much as how much high quality work is in progress. Judge the individual or center on their total quality score, not the absolute number of papers they produce. Sure, the sheer number of studies published will decline, but the quality will increase exponentially!

Tomorrow, the big picture view on how to detect bad research.