Trauma Education In The COVID Age

Trauma education has gotten significantly more difficult in the face of the Coronavirus. In-person education offerings like ATLS and PALS courses, TNCC courses, and major trauma conferences are routinely being cancelled or delayed. And many of them have decided to move to a virtual format.

Until early this year, I traveled around the country as a speaker for numerous trauma education conferences. The bulk of these have been cancelled for the remainder of the year. A few have opted to try an online format, and I will be giving several online talks in the coming months.

The American Association for the Surgery of Trauma (AAST) has converted their physical meeting in Hawaii to a virtual one (sigh). I will definitely be participating anyway!

Here are two conferences I will be speaking at, using the new virtual format. If you are in need of some quality education, check them out:

Virtual Excellence in Trauma Care Conference
Intermountain Medical Center – Salt Lake City UT
September 17-18, 2020
Presentations:
1. Keynote Address: Massive Bleeding Associated With Pelvic Fractures
2. Trauma Mythbusters
Registration Info: click here
Brochure: click here

Stormont Vail Trauma Symposium
Stormont Vail Hospital – Topeka KS
October 16, 2020
Presentations:
1. New Trends in Trauma
2. Mobility of the Trauma Patient in ICU
Registration and brochure: available soon

And if your hospital or organization is interested in putting your own grand rounds or other educational conference together, I am now focusing on providing presentations via telepresence.

Please check out the FAQ on my speaking engagements by clicking here.

Granted, telepresence is not the same as being there in person. It’s so much nicer to meet people in person, and it’s much more satisfying to make that more personal connection. But in-person conferences won’t be in the cards for a while. In the meantime, I hope to see you all soon via WebEx or Zoom! Please reach out!

Vascular And Nerve Injury After Knee Dislocation

There’s lots of dogma in trauma care, as well as in the field of medicine generally. The knee dislocation dogma is that the incidence of vascular injury is high (around 50%) with posterior dislocation, and somewhat lower with non-posterior dislocation.

At least that’s what I learned way back when. After recently finding myself spouting off those numbers, I wondered if it was really true. Our diagnostic imaging and vascular care has increased considerably in the last few decades, so I decided to check it out.

This nice image from EMDocs.net shows the various dislocation types. It also gives you an idea of why an associated vascular or nervous injury is so common.

(The nomenclature of the dislocation is based on the direction the tibia and fibula move with respect to the femur.)

The orthopedic surgery group at UCLA performed a meta-analysis of the literature relating to knee dislocation complications. They identified 7 papers describing the injuries of 862 patients.

Here are the factoids:

  • The overall incidence of vascular injury with knee dislocation was 18%, and nerve injury was 25%
  • The incidence of vascular injury with the various types of dislocation was:
    • Posterior dislocation: 25%
    • Anterior dislocation: 19%
    • Lateral dislocation: 18%
    • Medial dislocation: 7%
    • Rotatory: 14%
  • Disruption of both cruciate ligaments as well as the lateral or medial collateral ligament had a very high incidence of vascular injury (32% and 26% respectively)
  • About 80% underwent surgical repair of the popliteal artery, but the amputation rate was 12%(!)

Bottom line: The old dogma regarding vascular injury after knee dislocation may be a little exaggerated. However, it is still common after knee dislocation, and can lead to devastating complications.

If your patient tells you that they felt a popping sensation in their knee, or if they have a mechanism consistent with knee dislocation (e.g. pedestrian struck), be very suspicious for this injury. A thorough yet gentle exam should be performed, including good neurologic and vascular exams. Calculation of the Arterial Pressure Index (API) may be helpful, but will not keep you from obtaining imaging studies. Multi-plane imaging of the knee is required, and a CT angiogram/runoff study should be performed to exclude a vascular problem.

Reference: Vascular and Nerve Injury After Knee Dislocation: A Systematic Review. Clin Orthop Relat Res 472(9):2621-9, 2014.

The Peri-Mortem C-Section

The perimortem C-section (PMCS) is a heroic procedure designed to salvage a viable fetus from a moribund mother. Interestingly, in some mothers, delivery of the fetus results in return of spontaneous circulation.

The traditional teaching is that PMCS should be started within 4-5 minutes of the mother’s circulatory arrest. The longer it is delayed, the (much) lower the likelihood that the fetus will survive.

The reality is that it takes several minutes to prepare for this procedure because it is done so infrequently in most trauma centers. Recent literature suggests the following management for pregnant patients in blunt traumatic arrest (BTA):

  • Cover the usual BTA bases, including securing the airway, obtaining access and rapidly infusing crystalloid, decompressing both sides of the chest, and assessing for an unstable pelvis
  • Assess for fetal viability. The fundus must measure at least 23 cm.
  • Assess for a shockable vs non-shockable rhythm. If shockable, do two cycles of CPR before beginning the PMCS. If non-shockable, move straight to this procedure.

Bottom line: Any time you receive a pregnant patient in blunt arrest, have someone open the C-section pack while you assess and try to improve the mother’s viability. As soon as you complete the three tasks above, start the procedure! You don’t need to wait 4 minutes! And by the way, this is usually a procedure for surgeons only. They have the speed and skills to get to the right organs quickly. If unavailable, do what you need to do but recognize that the outcome may be even worse than it usually is.

Trauma Performance Improvement: How Often Should Your Committees Meet?

For those of you who are trauma performance aficionados, check out the newest posts on my PI site TraumaMedEd.com. There is a post for each of your required trauma program committees:

How Often Should My Multidisciplinary Trauma PI Committee Meet?

and

How Often Should My Trauma Operations Committee Meet?

And if you are interested in receiving email notices when new PI-related posts are available, please subscribe by clicking here!

The Eleventh Law Of Trauma

Here’s the last one… for now.

If you have followed this blog for any period of time, you are aware of the skepticism I bring to bear when I am reading new material or learning of new ideas. Why is this? Because it is very difficult in this day and age to ascertain the veracity of anything we see, hear, or read.

This is not new compared to, say, a hundred years ago. The media were a bit different, but the underlying issues were the same. There have always been two major factors at play: information overload and the biases built into our human brain operating system.

There is a huge body of new information in every field that is being produced every year. Given the pressures that most researchers are under to publish or perish, a huge number of papers are sent to journals for review. Unfortunately, this leads to a huge number of publications that are of lower quality.

This also contributes to another recognized phenomenon, the half-life of facts. Think about all the things you learned during your training that are no longer believed to be true. Stress causes ulcers. Steroids are good in head injury. There is a definite decay curve for the old facts that occurs as new knowledge is acquired.

So we have a huge amount of potential junk to sort through to figure out what cellular mechanisms are correct or which medications work for a disease. And then we run into our own operating system problems.

All humans have our own innate beliefs that are shaped by experience and all the information we’ve consumed over the years. And we are genetically programmed to do this:
Learn something new  —>  believe it  —>  verify it

And many of us never get to the verify stage because another operating system issue, confirmation bias, takes over. If we learn something that confirms an existing belief, we are much more likely to believe and much less likely to verify. If we learn something that opposes our belief, we still want to believe what we already do and find every flaw in the new data that might refute it.

So here is my eleventh law of trauma:

“Don’t believe anything you learn, especially if it supports what you already believe”

Bottom line: If you read or hear something new, first examine the source. Is it legitimate and reliable? Where did it get the info? Then check out that source. Critically evaluate it, even if it already supports what you believe. Always treat new information, especially if you think it’s right, as an opportunity to learn something new. Sometimes you will find real gems in the things you thought were wrong, and real crap in the things you believed to be right!

It’s time to flip the algorithm to:
Learn something new  —>  verify it  —>  believe it