Here’s an entertaining but insightful peek into the issues surrounding good vs bad science. It’s pitched to the lay public, but brings up a lot of the issues about the pressures of publishing, vagaries of study design, and why things get reported the way they do. Well worth the time (and laughs) to watch!
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.
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 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:
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).
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:
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!!
Reference: Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study. J Trauma 85(1):78-84, 2018.
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:
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