By popular demand, here’s our short (8 minute) humorous video on the basics of the extended FAST exam. Courtesy of Michael Zwank MD from Regions Hospital. From Trauma Education: The Next Generation 2014.
Everyone worries about patient satisfaction these days, and rightly so. There’s quality of care, and there’s satisfaction with it. The two are tough to separate. Many hospitals administer surveys and questionnaires after discharge about the overall hospital stay. But who looks at the experience of going through a trauma activation?
A very recent paper from Cornell and Penn interviewed trauma patients within 2 days of the trauma activation, and provided a $25 incentive to participate. There were 14 questions presented during a verbal interview, all open-ended. Patients with abnormal mental status during trauma activation were excluded, and data was collected over a 7 month period.
Here are the factoids:
- Most patients described fear and agitation, along with a loss of control
- 93% expressed concern about things other than themselves: family, work, safety
- Many patients remarked on the removal of their clothing. Some were concerned that they could not afford to replace them.
- Most participants noted that they received pain medicine early, but that it was not always effective immediately
- All participants described the team as caring and expert at what they do
- Patients appreciated the fact that team members introduced themselves and expressed concern for their wellbeing
- They were very observant of communication, and picked up on sidebar communications as well
Bottom line: Don’t underestimate what your patient observes and experiences during a trauma resuscitation. Unless head injured or intoxicated, they are picking up on everything you say and do. The trauma activation needs to be as patient-centered as possible while maintaining patient and team safety. Team members should be mindful of all communications, even when things are winding down. Try to spare patient clothing if possible. Use adequate analgesia and judicious sedation. And always remember to communicate clearly!
Reference: Patient experiences of trauma resuscitation. JAMA Surg 152(9):843-850, 2017.
There are about a quarter of a million physicians who are currently 65 or older and in practice. This represents about a quarter of those currently practicing. Unlike other professions like federal judges, FBI employees, and nuclear materials couriers, there is no mandatory retirement age for doctors. Although not forced to retire, commercial pilots are more closely monitored after they turn 65. But our profession has not really done a very good job of policing itself. It relies on voluntary action to identify struggling colleagues, who are generally reluctant to report a partner.
We are all living longer, and physicians are no exception. This means that many continue to practice well beyond the “customary” retirement age. What exactly happens to us? One study gave a quick cognitive test to a group of physicians and compared them to non-physician controls. Here are the results:
Ages ranged from 30-80 years. Note that the physician scores were consistently higher than the controls for all age groups, but declined significantly with age just like the controls. The big problem is that individuals have difficult recognizing (or accepting) their own cognitive decline.
The American College of Surgeons (ACS) assembled a workgroup to address this issue. They recommended that surgeons undergo voluntary, confidential testing of their baseline vision and physical examination starting at age 65-70, with regular re-evaluation afterwards. So far, only 3 or the more than 5,000 hospitals in the US do this. Canada has a mandatory age of 70 for commencing regular peer evaluations of competence. Obviously, the US does not.
There are really two components at play: wellness (which includes cognition) and competence. The problem is the neither correlates well with chronological age, but rather physiologic age. And the latter is impossible to quantify.
So what do we do? This is a problem that can’t be ignored from a patient safety standpoint. But it does not readily lend itself to simple pronouncements of a mandatory retirement age. There are many physicians who can and do provide excellent service to their patients well past the customary retirement age. They are able to apply a lifetime of lessons learned that their younger colleagues simply do not have.
We need uniform adoption of mandatory, not voluntary, testing of wellness and competence. Individual hospitals need to heed the recommendations of national organizations like the ACS to implement these mandatory programs to ensure fairness and avoid the specter of age discrimination lawsuits.
I’m no spring chicken anymore, and I think about this every time I find myself searching for the name of that weird retractor I need. How old is too old? What do you think?
Reference: The Aging Physician and the Medical Profession. JAMA Surgery 152(10):967-971, 2017.
If you’ve read my stuff for very long, you know I frown on sending unstable patients anywhere but to the OR. Instability tends to get worse, and that always happens at inopportune locations like hallways, elevators, and CT scanners. Imagine my surprise when I noticed an abstract being presented at the Clinical Congress of the American College of Surgeons this week suggesting that it was okay to scan hemodynamically unstable patients before “definitive therapy.”
Here’s the title:
“Computed tomography in hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage”
The devil is in the details and the language. This group from USC included all patients who were hemodynamically abnormal on arrival to the trauma bay but who normalized to SBP > 90 during the resuscitation were included. A total of 253 of these patients were reviewed over a 9 year period, and the usual variables were analyzed (mortality, complications, hospital, ICU, and vent days, etc).
Here are the factoids:
- Of the 253 patients studied, 45 went to straight to OR and 208 were taken to CT
- Injury severity was identical for the two groups
- Lengths of stay and mortality were not different, but only p values were given
- Patients taken to CT cleared their lactic acidosis faster (12 vs 5 hours), and used a bit less plasma and significantly less blood transfusions
- The OR group underwent more procedures (31% vs 13%), although what these were and when they were performed is not listed
Bottom line: The title of this abstract is misleading, and may fool those who don’t read the rest of the abstract. It should read:
“Computed tomography in previously hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage”
Someone who just skims through this issue of the journal may get the idea that it’s okay to scan an unstable patient. The authors are not saying this at all. If you read the conclusion carefully, you can see that the patients had to be resuscitated to a SBP > 90 before they considered taking to scan. And they did that for the majority of these patients.
The real question is, why do the scanned patients clear their lactic acidosis faster, need less blood, and undergo fewer procedures? It appears that there is some bias or selection process in play. Otherwise, why not use the magic CT scanner to make them all better?
Reference: Computed tomography in hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage. JACS 225(4S2):e175-176, 2017.
After yesterday’s analysis of a not-so-good pan-scan vs selective-scan abstract, it’s time for a little philosophy today. There seem to be two camps in the world of initial diagnostic testing for trauma: selective scanning vs scan everything. I admit that I am one of the former. Yes, the more tests you do, the more things you will find. Some will be red herrings. Some may be true positives, but are they important? Here’s the key question:
“If a tree falls in a forest and no one is around, does it make a sound?”
There is a clinical corollary to this question in the field of trauma:
“If an injury exists but no one diagnoses it, does it make a difference (if there would be no change in treatment)?”
Here’s an example. On occasion, my colleagues want to order diagnostic studies that won’t make any clinical difference, in my opinion. A prime example is getting a chest CT after a simple blunt assault. A plain chest xray is routine, and if injuries are seen or the physical exam points to certain diagnoses, appropriate interventions should be taken. But adding a chest CT does not help. Nothing more than the usual pain management, pulmonary toilet, and an occasional chest tube will be needed, and those can be determined without the CT.
Trauma professionals need to realize that we don’t need to know absolutely every diagnosis that a patient has. Ones that need no treatment are of academic interest only, and can lead to accidental injury if we look for them too hard (radiation exposure, contrast reaction, extravasation into soft tissues to name a few). This is how we get started on the path to “defensive medicine.”
Bottom line: Think hard about every test you order. Consider what you are looking for, what you might find, and if it will change your management in any way. If it could, go ahead. But always consider the benefits versus the potential risks, or what I call the “juice to squeeze ratio.”
- George Berkeley, A Treatise Concerning the Principles of Human Knowledge, 1734, section 45.
- paraphrased by William Fossett, Natural States, 1754.