All posts by TheTraumaPro

Why Create Practice Guidelines?

Practice guidelines are everywhere. More and more organizations have developed processes to create high quality ones. But why should we care? Do they improve what we already do?

Here are my reasons for using practice guidelines:

  • They provide a consistent way of approaching a clinical issue. Everybody working with the patient knows how things will be done, so they don’t have to remember the nuances that particular doctors or providers like.
  • They (hopefully) use the best and most valid scientific data to address the care issue, thus giving trauma professionals the opportunity to provide the best care we know of.
  • They decrease errors and complications by narrowing the number of choices available to providers.
  • They decrease waste for the same reason. For example, drawing blood every 6 hours vs daily for solid organ injuries can add up to three unneeded tests every day.
  • They provide our trainees with one good way to deal with the clinical issue. This is important when they move on to independent practice, and sometimes when taking standardized tests (boards).

Bottom line: If 10 trauma professionals deal with a given clinical problem 10 different ways, then none of them are doing it right! Develop a guideline that all of them can live with, based on current literature (if any). That way they can all be right for once, and our patients will reap the benefits.

In my next post, I’ll describe how to craft a good practice guideline.

How To: The Serial Abdominal Exam

How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.

Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems.

Here are the key points:

  • Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons.
  • Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
  • Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
  • Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
  • Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.

Thoughts On Traumatic Hematuria: Part 2

Yesterday, I discussed blood in the urine from a urethra. As I mentioned, there is typically not much from that particular injury. Today, I’ll dig into the three causes of real hematuria.

All of these tubes show gross hematuria except the one on the right.

  • Bladder injury. This can occur with either blunt or penetrating injury. The degree of hematuria is variable with stabs or gunshots, but tends to be much darker in blunt injury. This happens because the size of the bladder injury tends to be greater with blunt force. The bladder injury is not necessarily full-thickness with blunt trauma. It may just be some wall contusion and underlying mucosal injury. But frequently, with seat belt injury and/or A-P compression injuries to the pelvis (“open book”), the injury is full thickness.
    • Tip: If less than 50cc of very dark urine flow from the catheter upon insertion, it is likely that your patient has an intraperitoneal bladder rupture!
  • Ureteral injury. This injury is very rare. The most common mechanism is penetrating, but this structure is so small and deep that it seldom gets hit by naything. Patients with multiple lumbar transverse process fractures will occasionally have a small amount of hematuria, probably from a minor contusion. More often than not, the hematuria is microscopic, so we should never know about it.
  • Kidney injury. The most important fact regarding renal injury is that the degree of injury has no correlation with the amount of hematuria. The most devastating injury, a devascularized kidney, frequently has little if any gross hematuria. And conversely, a very minor contusion can produce very red urine.

So what about diagnosis? It’s easy! If you see gross hematuria, insert a foley catheter (if not already done) and order a CT of the abdomen/pelvis with contrast, as well as a CT cystogram. The latter must not be done using passive filling of the bladder with a clamped catheter. Contrast must be infused into the bladder under pressure to ensure a bladder injury can be identified.

CT scan is an excellent tool for defining injuries to kidney, ureter, and bladder, and will identify extravasation into specific places and allow grading. Specific management will be the topic of future posts.

Thoughts On Traumatic Hematuria: Part 1

I’ve seen a number of patients recently with bloody urine, and that is prompting me to provide some (written) clarity to others who need to manage this clinical problem. I’ll try to keep it organized!

There are two kinds of hematuria in trauma: blood that you can see with the naked eye, and…

Okay, so there’s only one. Trauma professionals do not care about microscopic hematuria. It does not change clinical management. Sure, your patient might have a renal contusion, but you won’t do anything about that. Or, he/she might have an infarcting kidney. And you can’t do anything about that. If you order a urinalysis, you might see a few RBCs. Don’t let this lead you down the path of looking for a source. You’ll end up ordering lots of tests and additional imaging, and generally will have nothing to show for it at the end. It’s not your job to spend good money on the very rare chance of finding something clinically significant.

Both of these specimens have blood in them. You can’t see it on the left, so don’t go looking for it with a microscope.

There are four sources of blood in the urine.

1. The first source does not generally cause hematuria, but can occasionally cause a few visible wisps of blood. That source is a urethral injury. The textbook teaching, and it’s good advice, is to look at the urethral meatus in your trauma patient, especially if you are contemplating insertion of a urinary catheter. If you see a few drops of blood, pause to consider. Sometimes, the blood is no longer visible, but might be present as a few well-placed drops on the patient’s underwear. So have a look at that, too, especially in patients with high risk injuries such as A-P compression pelvic fractures (think, lots of ramus fractures or pubic diastasis).

If you didn’t notice it and inserted the catheter anyway, you might see a few wisps of blood in the tubing as you place it. More often than not, this is just run of the mill irritation of the mucosa by the catheter, but always keep the possibility of an injury in mind.

Tomorrow, I’ll discuss the remaining three sources, and what to do about them.

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Video: The Most Educational Trauma Surgeon In The World

Several readers asked me to dust off this video yet again. Enjoy this parody of the Dos Equis “Most Important Man In The World” commercials. I love poking fun at myself, and the slow motion shot on the helipad is hysterical.

This video was part of the Trauma Education: The Next Generation conference produced several years ago. Enjoy, and please comment or give it a thumbs up on YouTube!

Michael