All posts by TheTraumaPro

Help Your PI Meetings Run Smoothly

Multidisciplinary Trauma PI Committee is an essential part of all trauma centers verified by the American College of Surgeons. A lot happens in that one hour (or so) meeting. But efficiency hinges on being prepared, and we’ve all experienced meetings where the case presentations just weren’t crisp.  Unfortunately, some of the committee members may not have even glanced at the record in advance, and try to catch up during the actual meeting!

What to do? Here’s a set of guidelines to help your presenters do the best job possible. They rely on advance preparation and good communication with your trauma program.

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Download a pdf copy of the guidelines here

And please comment with your own twists and turns on making trauma PI an efficient and meaningful process!

Trauma Coverage By Locum Tenens Surgeons

Trauma call coverage is not always easy to come by, especially at Level III and IV 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 quite a few 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) for 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 is absolutely required
  • Trauma CME – Recent changes in CME requirements by the American College of Surgeons have nearly eliminated this need. However, do you want a surgeon who does not keep up with trauma education on your call panel? If you allow this, prepare yourself for some interesting performance improvement issues. Make sure that all locums meet some basic requirement for CME or internal education program (IEP) before they start
  • Dissemination of committee proceedings – Make sure that this is well-documented. These surgeons must attend at least 50% of your required committee meetings. If they can’t make it, they must be aware of all items discussed, particularly if it involves their care. Use teleconferencing, or at least send them a (confidential) copy of the minutes.
  • 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 for some centers. They 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. And with the adoption of the new Resource Document (Orange Book), it’s even harder to use them. If you must, 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).

How Safe Is ED Thoracotomy?

A few weeks ago, I opened a survey to find out common practices regarding performing emergency thoracotomy (EDT) in the emergency department. This procedure is performed at one time or another in most higher level trauma centers. It’s very invasive and is performed in an area that is not really set up for major operative cases. Furthermore, the atmosphere can be chaotic, and stress levels run high.

How safe is this situation? How does personal safety balance out with saving your patient? There are many, many opportunities for injury during this procedure, with significant exposure to blood and other bodily fluids.

A recently published multi-center study examined the potential for exposure during EDT at 16 US trauma centers over a 1.5 year period (14 Level I, 2 Level II). The study was prospective and observational, and was based on questionnaires filled out by all personnel involved in each procedure. A total of 1360 providers submitted information on 305 EDTs.

Here are the factoids:

  • Mechanism was penetrating in 77% of patients, who were predominantly young and male (91%)
  • 15 patients survived (5%), and 4 had residual neurologic impairment
  • Only 56% of respondents wore full personal protective equipment (PPE)
  • There was a 7% exposure rate per EDT(22 incidents), and 1.6% rate per participant in the case
  • The majority of those exposed were trainees (68%) who were injured by something sharp (scalpel 39%, fracture 28%, needle 17%, scissors 3%)
  • There was a strong correlation with PPE use and no exposure during the procedure
  • Only 92% followed their hospital’s occupational exposure protocol if injured (!!!)

Bottom line: Emergency thoracotomy will always be a dangerous procedure. Things happen quickly, there is little time to properly prepare and sharp, pointy things are everywhere. But according to this paper, the actual exposure rate is low. Factoring in the risk of disease transmission, the risk to an individual provider of contracting HIV is 1 in a million, and for hepatitis C is 3 in 100,000

The most distressing part of this study, to me, was the sense of invulnerability of a few of the participants. How can anyone justify not wearing full PPE during an emergency thoracotomy? I believe this represents a very casual attitude toward wearing PPE in any resuscitation. But this study clearly shows a large decrease in exposure rate when full PPEs are worn. Even more disturbing? The fact that 8% chose not to protect themselves by following their own institution’s occupational exposure protocol. Unforgivable!

The main takeaway messages are: always wear your PPE to a trauma resuscitation because you never know when you’ll need to get invasive (and won’t have time to dress up then), and be careful!!

Using MRI To Predict Outcome From Diffuse Axonal Injury (DAI)

Has this happened to you? A patient with a serious head injury is not waking up as expected. There were a few punctate hemorrhages seen on the initial CT scan. Your neurosurgery colleague orders an MRI to “provide a prognosis on the patient’s injury.”

Is this a legitimate request? Sure, MRI is very sensitive at detecting very small hemorrhages that may signal the presence of diffuse axonal injury (DAI). But do more abnormalities on MRI equal a poorer prognosis or longer recovery time?

A group from Vanderbilt presented their data from a retrospective cohort study at EAST earlier this year.  They reviewed 7 years of data from 2006 to 2012, including all patients with a head CT positive for intracranial injury and an MRI within 2 weeks. They excluded penetrating injuries and patients with psychiatric or neurologic disorders. They analyzed information on three year mortality, functional outcome, and quality of life.

Here are the factoids:

  • A total of 311 patients met all inclusion/exclusion criteria, with a median age of 40 and serious injury (average ISS 29, average ICU length of stay 6 days)
  • Functional status at discharge could be assessed in 240 patients, and only 118 could be contacted for long-term followup questions
  • Only 56% of patients with severe TBI had an MRI positive for DAI
  • Functional status was lower on discharge for patients positive for DAI on MRI
  • There was no difference in Glasgow Outcome Score, quality of life, or 3 year survival in patients with MRI evidence of DAI compared to those without

Bottom line: This is a relatively large study, but there are still several weaknesses that could skew the numbers a bit. However, it appears that MRI for prognostication of outcomes in patients with clinical DAI is not very helpful. First, only about half with a clinical picture of DAI showed it on MRI. And sure, MRI may tell us a little bit about their status when they are discharged from the hospital to rehab or transitional care. But is that information very useful? It certainly does not help predict their outcome in the longer term. So why order an expensive and difficult study (think restraints, sedation, lots of pumps and monitors) to tell us what we already know based on our experience with severe TBI?

Reference: Prognosis of diffuse axonal injury with traumatic brain injury. J Trauma 85(1):155-159, 2018

Systemic Air Embolism From Chest Trauma

Systemic air embolism (SAE) is an uncommonly encountered but potentially catastrophic complication that trauma professionals will probably see only once or twice in their career. In a couple of very old papers (30-35 years!), it was said to occur in 4 to 14% of patients with severe lung trauma. The pathognomonic finding is complete cardiovascular collapse shortly after intubation and positive pressure ventilation of a patient with significant chest trauma.

SAE can occur after major blunt or penetrating injury. Normally, pressure in the pulmonary arterial and venous branches of the lungs is higher than that of air in the bronchi. If lung parenchyma is torn by gunshot, stab, or blunt pulmonary laceration, then blood can leak into the smaller airways. Unless a major vessel is torn, the volume lost is not of much consequence. A small amount of hemoptysis may be present.

But if positive pressure is applied to the airways, air may be forced into those vascular structures. If the injury involves a pulmonary vein, the gas bubbles enter the left heart and and then the systemic circulation. Only a cc or two of air in the cerebral circulation or coronary arteries can cause a rapidly fatal condition.

How can a trauma professional suspect that a patient may be susceptible to SAE? Look for evidence of hemoptysis in patients with penetrating chest injury or severe blunt chest trauma. Unfortunately, this occurs in only a few patients and its absence is not helpful.

Always suspect SAE if your patient suffers circulatory collapse or arrest shortly after intubation and positive pressure ventilation. This is especially true in patients who were very stable up until that point. Ultrasound may be used to detect air bubbles in the left heart. Transesophageal echo is even better, but not readily available in the ED.

What can be done if your patient (nearly) arrests after intubation and you suspect SAE? The recommended treatment is single lung ventilation and thoracotomy on the injured side. The injured side is obvious in patients with unilateral penetrating injury, but much more difficult to determine in blunt trauma where either lung may be involved. A quick chest x-ray could be obtained, but may not localize the injured lung.

If the left lung is involved, push the endotracheal tube into the right mainstem bronchus to eliminate the abnormal pressure gradient in the injured lung. If the right lung in injured, a dual lumen endotracheal tube should be inserted for single-lung ventilation. Unfortunately, this requires fiberoptic tools and is not available in the field or most emergency departments.

If single-lung ventilation can be accomplished, this may buy some time to try to resuscitate your patient. A thoracotomy of the injured side can also be carried out to occlude the hilum of the lung in an attempt to stop any further embolism. Initial clamping should be carried out by hand, as using a crushing clamp commits the patient to an emergency pneumonectomy (if they survive beyond this point).

Overall survival is dismal. Old data suggests that more than 80% of blunt trauma victims with SAE die, as well as half of patients with penetrating injury. These numbers are even lower once the patient arrests. The key to survival is avoiding unnecessary intubation in patients with potential SAE, and moving to single-lung ventilation quickly in those who have developed it.