Most trauma centers have a book of practice protocols or guidelines. Actually, it is required by the American College of Surgeons verification standards. All centers must have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes arises: why do we need another protocol? Why can’t I do it my own way?
I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols/guidelines.
In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.
- They allow us to build in adherence to any known literature support (evidence based).
- They help conserve resources by standardizing care orders and resource use. This means they save money!
- They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
- They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
- They promote team building, particularly when the protocol components involve several different services within the hospital.
- They teach a consistent, workable approach. This is especially important to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.
Tomorrow, I’ll write about imaging guidelines, and how they can help avoid VOMIT (victims of medical imaging technology).
Bottom line: It’s interesting that there are so many articles about practice guidelines, but very few explaining why they are important. Although the proof is not necessarily apparent in the literature, protocol and guideline development is important for trauma programs for the reasons outlined above. But don’t develop them just so you can have an encyclopedia of fifty! Identify common problems that can benefit from the consistency they provide. It will turn out to be a very positive exercise and reap the benefits listed above.
Many trauma patients require implantable hardware for treatment of their orthopedic injuries. One of the concerns they frequently raise is whether this will cause a problem at TSA airport screening checkpoints (Transportation Safety Administration).
The answer is probably “yes.” About half of implants will trigger the metal detectors, and these days that usually means a pat down search. And letters from the doctor don’t help. It turns out that overall, 38% are detected when the scanner is set to low sensitivity and 52% at high sensitivity.
Here is a more detailed breakdown:
- Lower extremity hardware is detected 10 times more often than upper extremity or spine implants
- 90% of total knee and total hip replacements are detected
- Upper extremity implants such as shoulder, wrist and radial head replacements are rarely detected
- Plates, screws, IM nails, and wires usually escape detection
- Cobalt-chromium and titanium implants trigger alarms more often than stainless steel
If your patient knows that their implant triggers the detectors, they have two options: request a patdown search, or volunteer to go through the full body millimeter wave scanner. This device looks at everything from the skin outwards, and will not “see” the implant and is probably the preferred choice. If they choose to go through the metal detector and trigger it, they are required to have a patdown. Choosing to go through the body scanner after setting off the detector is no longer an allowed option.
Reference: Detection of orthopaedic implants in vivo by enhanced-sensitivity, walk-through metal detectors. J Bone Joint Surg Am. 2007 Apr;89(4):742-6.
Seriously injured patients frequently develop coagulopathy, which makes resuscitation (and survival) more challenging. A few years ago, the CRASH-2 study lent support for using tranexamic acid (TXA) in select trauma patients to improve survival. This drug is cheap and has antifibrinolytic properties that may be beneficial if given for life-threatening bleeding within 3 hours of initial injury. It’s typically given as a rapid IV infusion, followed by a slower followup infusion. The US military has adopted its routine use at forward combat hospitals.
But what if you don’t have IV access? This can and does occur with military type injuries. Surgeons at Madigan Army Medical Center in Washington state tried using a common alternative access device, the intraosseous needle, to see if the results were equivalent. This study used an adult swine model with hemorrhage and aortic crossclamping to simulate military injury and resuscitation. Half of the animals then received IV TXA, the other half had it administered via IO. Only the bolus dose was given. Serum TXA levels were monitored, and serial ROTEM determinations were performed to evaluate coagulopathy.
Here are the factoids:
- The serum TXA peak and taper curves were similar. The IV peak was higher than IO and approached statistical significance (0.053)
- ROTEM showed that the animals were significantly hyperfibrinolytic after injury, but rapidly corrected after administration of TXA. Results were the same for both IV and IO groups.
Bottom line: This was a very simple and elegant study. The usual animal study issues come into play (small numbers, pigs are not people). But it would be nearly impossible to have such a study approved in humans. Even though the peak TXA concentration via IO is (nearly significantly) lower, this doesn’t appear to matter. The anti-fibrinolytic effect was very similar according to ROTEM analysis.
From a practical standpoint, I’m not recommending that we start giving TXA via IO in civilian practice. We don’t typically see military style injuries, and are usually able to establish some type of IV access within a reasonably short period of time. But for our military colleagues, this could be a very valuable tool!
Reference: No intravenous access, no problem: Intraosseous administration of tranexamic acid is as effective as intravenous in a porcine hemorrhage model. J Trauma 84(2):379-385, 2018.
In this day and age of ride sharing apps like Uber and Lyft, it is possible to get a cheap ride virtually anywhere there is car service and a smart phone. And of course, some people have used these services for transportation to the hospital in lieu of an ambulance ride. What might the impact be of ride services on patient transport, for both patient and EMS?
A paper in preparation suggests that ambulance service calls decreased by 7% after the introduction of UberX rides. Now, there are a lot of questions here, because the full paper has not yet been peer reviewed, and the results write-up is pretty sketchy. But it does beg the question.
Ambulance rides are expensive. Depending on region, they may range from $500-$5000. And although insurance may reduce the out of pocket cost, it can still be expensive. So what are the pros vs the cons of using Uber or Lyft for medical transport?
- Ride shares are inexpensive compared to an ambulance ride
- They may arrive more quickly because they tend to circulate around an area, as opposed to using a fixed base
- Riders may select their preferred hospital without being overridden by EMS (although it may be an incorrect choice)
- May reduce EMS usage for low acuity patients
- No professional medical care available during the ride
- May end up being slower due to lack of lights and siren
- Damage fees of $250+ for messing up the car
Bottom line: Uber and Lyft are just another version of the “arrival by private vehicle” paradigm. Use of these services relies on the customer/patient having very good judgment and insight into their medical conditions and care needs. And from personal experience, this is not always the case. I would not encourage the general public to use these services for medical transport, and neither do the companies themselves!
Reference: Did UberX Reduce Ambulance Volume? Unpublished paper, October 24, 2017.
Traumatic brain injury (TBI) is an extremely common diagnosis in trauma patients. The majority are minor concussions that show no evidence of injury on head CT. Despite normal findings, however, a short conversation with the patient frequently demonstrates that they really do have a TBI.
Scoring systems can help quantify how significant the head injury is. The Glasgow Coma Scale (GCS) score is frequently used. This scoring system is not sensitive enough for minor head injuries, since a patient may be perseverating even with a GCS of 15.
The Short Blessed Test (SBT) is a 25 year old scoring system for minor TBI that has been well-validated. It takes only a few minutes to administer, and is very easy to score.
The most important part of the administration process is choosing a threshold for further evaluation and testing. We administer this test to all trauma patients with a suspected TBI (defined as known or suspected loss of consciousness, or amnesia for the traumatic event). If the final score is >7, we refer the patient for more extensive evaluation by physical and occupational therapy. If the score is 7 or less but not zero, consideration should be given to offering routine followup in a minor neurotrauma clinic as an outpatient. In all cases, patients should be advised to avoid situations that would lead to a repeat concussion in the next month.
Reference: Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983 Jun;140(6):734-9.