All posts by The Trauma Pro

Tips

How To MacGyver A Ventilator From Common Parts

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A cardiac anesthesiology fellow, and several engineers from the University of Minnesota and a local device company got together over the past few weeks and cobbled together a ventilator from some spare parts. Here’s a picture to give you an idea of what it looks like:

It uses a metal toolbox tray, an Ambu bag, and some other spare parts lying around one of the medical device labs at the university. Essentially, a servo motor intermittently squeezes the Ambu bag, and there are adjustments for how often (rate) and how deeply (volume) the bag is compressed. There is a pressure limiting device included in the system as well.

This project illustrates how we will need to think outside the (tool)box in the coming weeks, especially as the number of severe Coronavirus cases begins to tax our supply of ventilators. And obviously, this thing will not get FDA approval in your lifetime. But if a choice needs to be made between using something like this in a pinch vs letting someone asphyxiate, the answer is pretty clear.

The group has produced a short YouTube video as well (see below), but it is rather short on details. You get to see some partial views of it as it is being tested on pigs. But so far, the concept is promising.

If you are trying to view this on my Tumblr feed, the video will not show here. Please click here to visit my main blog site to view it.

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Tips

Coronavirus: Using One Ventilator To Ventilate Up To Four Patients

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It’s unusual for me to post on a Saturday, but we are currently living in unusual times. This tidbit caught my attention and I wanted to get this interesting idea out there for all to think about.

Hopefully, it will never come to this. But there are reports from both Italy and New York City that ventilators are in short supply. This video illustrates the technique used in some research that was actually published way back in 2006. It demonstrated the efficacy of using one ventilator on four patients at once.  It requires just a few connectors that are readily available.

But remember, this is off-label use and is not condoned by the FDA! And it probably violates every Department of Health and hospital policy written. But in a pinch, it is something to think about.

Obviously, there are lots of possible downsides. Four patients are essentially sharing one circuit. Even though the circuits are one-way, there is always an infectious cross-contamination risk. The paper shows that ventilation should be adequate on both pressure and volume control settings.

This type of thing is a very last resort, and hopefully no one will have to use it!

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Reference: A single ventilator for multiple simulated patients to meet disaster surge. Acad Emerg Med 13(11):1246-9, 2006.

Philosophy

Coronavirus (COVID-19) And Your Trauma Service

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In my last post, I made some suggestions on how to modify the trauma activation process to better protect your team members from exposure to the Coronavirus. Today, I’ll discuss some things you can do to reduce the exposure of your in-house team that provides care for patients.

First off, I’m not going to discuss the obvious things like personal protective equipment, or what to do when performing risky procedures such as intubation or extubation. Those have been covered elsewhere and each hospital has adopted its own standards.

I will be discussing more general concepts that help limit team member exposure to possible contamination or infected individuals. Here are some of my suggestions:

  • Make sure your hospital conserves the resources it needs to be a trauma center. A certain number of ICUs, operating rooms, and floor beds must be reserved for trauma patients. Your hospital should make contingency plans such that if COVID-19 patients are getting close to taking too many beds or other resources, there is an escape valve so they can be diverted or transferred to other non-trauma hospitals.
  • Save your trauma surgeons for things only they can do. Many hospitals have general surgeons on staff in addition to their trauma/critical care surgeons. Remove the trauma surgeons from emergency general surgery / acute care surgery services and concentrate them on the trauma and critical care services. Have the general surgeons cover the other services, and send all idle trauma surgeons home where it is safer. Rotate them through trauma and critical care on a regular basis. Imagine what would happen if you lose 2 or 3 of your trauma surgeons at the same time, and don’t let it happen to you!
  • Eliminate non-essential meetings and conferences. This includes morbidity and mortality conferences, journal clubs, and all educational conferences. These things have to go on the back burner for now and can be re-instituted once things return to normal.
  • Practice social distancing at essential meetings. Certain gatherings are unavoidable, such as care handoffs (“morning report,” and “afternoon check-out”). Reduce the attendees to only those whose input is critical. If needed, they can gather information from other small groups of providers to prepare for the essential meeting. But no more crowded rooms, please.
  • Don’t congregate with other providers unnecessarily. This means outside your office, in the lounge, and in the lunchroom. The usual social norms need to take a back burner to your own safety and health.
  • Use telephone conferencing as much as possible. You will be surprised at how many of these less-than-essential meetings can be handled virtually, or eliminated. One tip, though: print a copy of the agenda for reference. It seems to be more difficult to follow the flow of the meeting (and take/make notes) if you don’t have something you can visually refer to.
  • Redesign your care team. Do you really need your entire team (APPs, residents, nurses) hanging around all day like they usually do? The reality is that the bulk of the work on any trauma service generally takes place in the morning. The rest of the day is spent waiting for incoming trauma patients. Calculate the optimal number of providers based on your service census. Do the morning work, go on rounds (smaller groups, please), finish any post-rounds chores, then send the extras home. And rotate those providers so that some can spend time at home while the others are in-house.
  • Use residents wisely if you have them. They are part of your care team, too, so be sure to minimize their exposure. The previous tip on redesigning the care team applies to them, too. And frequently, they rotate through several hospitals, many of which are not doing elective surgery. So they may not have a lot to do. Work with the residency program director to see if you can temporarily add them to the trauma center coverage pool. This allows you to keep a larger number of residents at home while maintaining a reasonable number for your care team.

In my next post, I’ll cover changes you should consider in your Massive Transfusion Protocol.

Philosophy

Coronavirus (COVID-19) And Your Trauma Team

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We are in the midst of Coronavirus mania! Every hospital in the country is scrambling to figure out what to do to meet the rapidly increasing demand for screening and access to care that has been so unexpectedly thrust upon us.

Trauma professionals will be profoundly affected as well. We are a scarce resource in the first place, and I’m speaking of those in all disciplines from prehospital through rehab. And since the SARS-CoV-2 virus seems to be so widespread and our testing abilities so limited, it is a challenge to protect ourselves from contracting it. Given how scarce we are, losing even a few to self-imposed quarantine (or worse) would be very disruptive to the health care of the trauma patients we normally take care of.

The key is to try to limit exposure to the Coronavirus as much as possible. Hospitals are now very diligent about screening patients and their families as they enter the hospital. However, the trauma activation patient is a potential wild card.

What can be done to protect the trauma professionals assembling to take care of a trauma activation patient, who should probably be considered infected until proven otherwise? The most obvious answer is to escalate the normal personal protective measures to include the same garb worn for treating patients with known or suspected infection. This includes N95 masks and full face shields.

Unfortunately, this is not practical due to the extreme shortages of this equipment. But what we can do is optimize our trauma team and provide a more informed and graduated response.

Here are my recommendations:

  • Drastically reduce overtriage. Most busy trauma centers have overtriage rates (trauma activation for patients with low acuity and/or do not meet activation criteria) around 50%, and sometimes higher. Frequently, these are patients who did not really need to be met by the full trauma team. How can you do this?
    • Eliminate superfluous activation criteria; keep only your physiologic and anatomic ones. These generally correlate with Steps 1 and 2 of the CDC triage criteria for transfer to a trauma center used by your EMS providers. Eliminate all mechanism of injury criteria except for penetrating injury. This includes falls, pedestrian struck, vehicle intrusions, etc. Then eliminate anything else that doesn’t fall into these categories. You are essentially converting to a bare bones single-tier activation system.
    • Eliminate the ability of prehospital providers to call a field activation on anything other than your activation criteria (or Step 1 and Step 2 CDC criteria. This may be difficult or confusing if they service several centers that normally have different criteria. The person taking the radio/phone call and initiating the team page should not activate the team unless one of the physiologic or anatomic criteria are specifically mentioned. All other transports should be met by an emergency physician who will then use their clinical judgement to activate the full team.
  • Eliminate superfluous trauma team members. This includes students, shadowing providers, observers, extra residents, and anyone else who does not have an essential role in the room.
  • Call the entire team, but only use who you need. Determine the makeup of your core team. One physician, two nurses, a tech, and a scribe? This will vary by center. They should dawn protective gear that is as effective (and available) as possible. (This may not be face shields and N95 masks if you are a busy center and don’t have many in stock.) The others should remain available outside the room and be called in only if necessary (pharmacist, respiratory therapy, additional physicians or APPs, etc). All other normal team personnel can then be dismissed and disperse.
  • Release active team members who are no longer needed. As the resuscitation winds down and team members complete their tasks, send them away.
  • Reduce the post-resuscitation transport team to the minimum necessary. This will depend on the patient’s condition. Are they stable, awake, and alert? Or intubated and traveling with a rapid infuser? Assign personnel appropriately.

Bottom line: Things have changed for a while and the old rules may not completely apply. Critically look at everything you do to see if it is still reasonable and necessary. Always keep the safety of your patient at heart. But don’t lose sight of the fact that you won’t be able to help anyone in the future if you are quarantined at home.

This crisis will only last for a few months, but it should cause us to question business as usual. We may discover that some of what we do is not a necessary as we thought!

I’m very interested in what others are doing with their resuscitation teams and trauma services to increase safety. Please share on Twitter, or feel free to email me.

General

Trauma Activation Patients Staying Too Long In Your ED?

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One of the long-held beliefs in trauma care relates to the so-called “golden hour.” Patients who receive definitive care promptly do better, we are told. In most trauma centers, the bulk of this early care takes place in the emergency department. However, for a variety of reasons, throughput in the ED can be slow. Could extended periods of time spent in the ED after patient arrival have an impact on survival?

Wake Forest looked at their experience with nearly 4,000 trauma activation patients who were not taken to the OR immediately and who stayed in the ED for up to 5 hours. They looked at the impact of ED dwell time on in-hospital mortality, length of stay and ventilator days.

Overall mortality was 7%, and the average time in the ED was 3 hours and 15 minutes. The investigators set a reasonable but arbitrary threshold of 2 hours to try to get trauma activation patients out of the ED. When they looked at their numbers, they found that mortality increased (7.8% vs 4.3%) and that hospital and ICU lengths of stay were longer in the longer ED stay group. Hospital mortality increased with each hour spent in the ED, and 8.3% of patients staying between 4 and 5 hours dying. ED length of stay was an independent predictor for mortality even after correcting for ISS, RTS and age. The most common cause of death was late complications from infection.

Why is this happening? Patients staying longer in the ED between 2 and 5 hours were more badly injured but not more physiologically abnormal. This suggests that diagnostic studies or consultations were being performed. The authors speculated that the knowledge, experience and protocols used in the inpatient trauma unit were not in place in the ED, contributing to this effect.

Bottom line: This is an interesting retrospective study. It reflects the experience of only one hospital and the results could reflect specific issues found only at Wake Forest. However, shorter ED times are generally better for other reasons as well (throughput, patient satisfaction, etc). I would encourage all trauma centers to examine the flow and delivery of care for major trauma patients in the ED and to attempt to streamline those processes so the patients can move on to the inpatient trauma areas or ICU as efficiently as possible.

Reference: Emergency department length of stay is an independent predictor of hospital mortality in trauma activation patients. J Trauma 70(6):1317-1325, 2011.