All posts by TheTraumaPro

What Would You Do? Nail In The Neck

Here’s a very interesting case for you. A construction worker was carrying an object inside a building WHILE HOLDING HIS NAIL GUN! As he passed through the door, his elbow hit the frame and he brushed his neck with the business end of the gun. Guess what happened?

He experienced sharp pain, then noted pain every time he swallowed. He checked himself out in the mirror, and there was a small puncture wound in the right side of his neck. He presented to his local ED, with the complaints just noted. He was hemodynamically stable and neurologically intact. His airway was patent, and he had minimal pain. The following image was obtained. The nail measures about 6cm in length.

 

Let me know (by Twitter or comments) what additional information you think you need. I’ll discuss that tomorrow, then on Monday we’ll figure out what to do about this problem.

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Why Do Trauma Patients Get Readmitted?

Readmission of any patient to the hospital is considered a quality indicator. Was the patient discharged too soon for some reason? Were there any missed or undertreated injuries? Information from the Medicare system in the US (remember, this represents an older age group than the usual trauma patient) indicates that 18% of patients are readmitted and 13% of these are potentially preventable.

A non-academic Level II trauma center in Indiana retrospectively reviewed their admissions and readmissions over a 3 year period and excluded patients who were readmitted on a planned basis (surgery), with a new injury, and those who died. This left about 5,000 patients for review. Of those, 98 were identified as unexpected readmissions. 

There were 6 major causes for readmission:

  • Wound (23) – cellulitis, abscess, thrombophlebitis. Two thirds required surgery, and 4 required amputation. All of these amputations were lower extremity procedures in obese or morbidly obese patients.
  • Abdominal (16) – ileus, missed injury, abscess. Five required a non-invasive procedure (mainly endoscopy). Only 2 required OR, and both were splenectomy for spleen infarction after angioembolization.
  • Pulmonary (7) – pneumonia, empyema, pneumothorax, effusion. Two patients required an invasive procedure (decortication, tube placement).
  • Thromboembolic (4) – DVT and PE.  Two patients were admitted with DVT, 2 with PE, and 1 needed surgery for a bleed due to anticoagulation.
  • CNS (21) –  mental status or peripheral neuro exam change. Eight had subdural hematomas that required drainage; 3 had spine fractures that failed nonoperative management. 
  • Hematoma (5) – enlargement of a pre-existing hematoma. Two required surgical drainage.

About 14% of readmissions were considered to be non-preventable by a single senior surgeon. Wound complications had the highest preventability and CNS changes the lowest. Half occurred prior to the first followup visit, which was typically scheduled 2-3 weeks after discharge. This prompted the authors to change their routine followup to 7 days. 

Bottom line: This retrospective study suffers from the usual weaknesses. However, it is an interesting glimpse into a practice with fewer than the usual number patients lost to followup. The readmission rate was 2%, which is pretty good. One in 7 were considered “preventable.” Wounds and pulmonary problems were the biggest contributors. I recommend that wound and pulmonary status be thoroughly assessed prior to discharge to bring this number down further. Personally, I would not change the routine followup date to 1 week, because most patients have far more complaints that are of little clinical importance than compared to 2 weeks after discharge.

Reference: Readmission of trauma patients in a nonacademic Level II trauma center. J Trauma 72(2):531-536, 2012.

What To Do About The Nasty Patient

We’ve all taken care of them. The nasty patient. Sure, trauma can ruin one’s day. And a person can’t be expected to be on their best behavior after, say, a major car crash. But after the dust settles and the patient is recovering, we sometimes get a glimpse of their real personality. And sometimes, it turns out, they are just not really that nice.

Most patients don’t realize that being nasty to their caregivers creates problems for themselves. Yes, we are trauma professionals, and we should be able to take care of anybody, anytime, under any circumstances. But human nature is what it is. We unconsciously try to minimize discomfort. And this may mean unconsciously reducing cares and interpersonal communication with the offensive individual.

The most important thing we can do is to make sure that the patient is aware that their behavior is not acceptable, and to set strict limits. A tight feedback loop is important. Equally as important, every provider needs to have the same limits, so the patient can’t play them against each other, trying to manipulate the system. Often times, the mere fact that the patient knows that the entire team has a uniform set of limits and expectations can help shape their behavior. This lets them recover as quickly as possible, and get out of the hospital at the earliest opportunity.

How can we accomplish this? Our hospital has developed a sort of “behavioral contract” that is provided to potential problem patients (and their visitors/families) to shape behavior before it has a chance to deteriorate. Nurses and/or doctors review the contract with the patient, explaining each point. They are them asked to sign, but even if they refuse, they are told they are still bound by it. Every trauma professional involved knows the limits so there is no room for manipulation. Here’s a copy of ours:

Have a look at our behavioral contract, and let me know your thoughts, or share the tools and tips you use to deal with this issue.

Download the behavioral contract here

The April newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Prehospital.

In this issue you’ll find articles on:

  • EMS Handoff
  • Safe aeromedical transport
  • Evaluated but not transported by EMS?
  • And more!

Subscribers received the newsletter first on Friday. If you want to subscribe (and download back issues), click here.

Download the newsletter here!

Evaluation of Hematuria in Blunt Trauma

Hematuria ranges from microscopic to gross. Microscopic means blood that can only be seen with a microscope, and gross means visible to the naked eye. In trauma, we only care about gross hematuria, which ranges from the faintest of pink to the deepest red.

In trauma, gross hematuria is a result of an injury to kidney, ureter or bladder. Blunt injury to the ureter is so rare it’s reportable, so you can pretty much forget that one unless the mechanism is extreme. So you really just need to focus on kidney and bladder.

Any victim of blunt trauma that presents with visible hematuria needs to be evaluated by CT of the abdomen and pelvis with an added CT cystogram. Standard CT technique is done without a urinary catheter, or with the catheter clamped. Only 50% of bladder injuries show up with this technique.

CT cystogram is an add-on to the standard CT, and consists of the administration of contrast into the bladder which is then kept under pressure while the scan is done. Delayed slices through the pelvis after the bladder is depressurized and emptied is routine. Nearly 100% of bladder injuries are detected using this technique.

If the CT shows a renal laceration or hematoma, the patient should be admitted and managed according to your solid organ injury protocol. Kidney injuries fare better that livers and spleens, and only rarely require surgery. If no kidney or bladder injury is seen, the default diagnosis of a renal contusion is the culprit. No treatment is needed, and the patient can be discharged if no other injuries are present. The blood will clear over a few days, but may disappear and reappear a few times in the process. The patient can followup with their primary care physician in a week or two.