I’m going to dedicate this week to discussing the impact of the electronic health record (EHR) on trauma care.
First, I’ll talk a little about the history of the EHR, how it came about and why it was “encouraged” of all hospitals. I’ll also look at who the big players are. Next, I’ll review two studies of the impact of the EHR on ED productivity and patient stay.
And finally, I’ll really dig into using an electronic trauma flow sheet that interfaces with the EHR. My thinking has slowly been changing, but not by much. I’ll review my reasons, and talk about the (few) success stories that are out there.
Anatomy is complex and confusing at times. Pretty much everything you can find in the human body has a name. Sometimes it makes sense. Sometimes it’s named after someone famous. And sometimes, it’s just a head-scratcher.
Let’s take the surgical neck of the humerus. Here’s an image of the proximal humerus:
Notice there are two different “necks” of the humerus. You are probably familiar with the anatomic neck from your anatomy classes. But if you are a resident, an orthopedic surgeon, or someone who deals with fractures regularly, you are more familiar with the surgical neck.
The surgical neck of the humerus is the most common fracture site on the proximal humerus. But here’s the kicker. It’s a misnomer!
Just because you see a fracture of the surgical neck of the humerus doesn’t meed it needs surgery! Indeed, many of these fractures are now successfully treated with immobilization in a sling. Your friendly neighborhood orthopedic surgeons will assess fracture stability by looking at the mechanism, exact location, involvement of the tubercles, and motion. Then they will decide on their treatment plan.
Bottom line: Don’t get suckered when someone asks you what operation is usually needed for a fracture of the surgical neck of the humerus!
‘Tis the season to see hypothermic patients again! The optimal way to warm them up has been debated for years. A number of very interesting techniques have been devised. Ever wonder how fast / effective they are?
I’ve culled data from a number of sources, and here is a summary what I found. And of course, the disclaimer: “your results may vary.”
||Rate of Rewarming
|Passive external (blankets, lights)
||0.5° C / hr
|Active external (lights, hot water bottle)
||1 – 3° C / hr
||2.4° C / hr
|Hot inspired air in ET tube
||1° C / hr
||2 – 3° C / hr
|GI tract irrigation (stomach or colon, 40° C fluid, instill for 10 minutes, then evacuate)
||1.5 -3° C / hr
|Peritoneal lavage (instill for 20-30 minutes)
||1 – 3° C / hr
|Thoracic lavage (2 chest tubes, continuous flow)
||3° C / hr
|Continuous veno-venous rewarming
||3° C / hr
|Continuous arterio-venous rewarming
||4.5° C / hr
|Mediastinal lavage (thoracotomy)
||8° C / hr
||9° C / hr
|Warm water immersion (Hubbard or therapy tank)
||20° C / hr
I’ve watched it happen for years. A trauma patient is admitted with a small subarachnoid hemorrhage in the evening. The residents put in all the “usual” orders and tuck them away for the night. I am the rounder the next day, and when I saunter into the patient’s room, this is what I find:
They were made NPO. And this isn’t just an issue for patients with a small head bleed. A grade II spleen. An orbital fracture. Cervical spine injury. The list goes on.
What do these injuries have to do with your GI tract?
Here are some pointers on writing the correct diet orders on your trauma patients:
- Is there a plan to take them to the operating room within the next 8 hours or so? If not, let them eat. If you are not sure, contact the responsible service and ask. Once you have confirmed their OR status, write the appropriate order.
- Have they just come out of the operating room from a laparotomy? Then yes, they will have an ileus and should be NPO.
- Are they being admitted to the ICU? If their condition is tenuous enough that they need ICU level monitoring, then they actually do belong to that small group of patients that should be kept NPO.
But here’s the biggest offender. Most trauma professionals don’t think this one through, and reflexively write for the starvation diet.
- Do they have a condition that will likely require an emergent operation in the very near future? This one is a judgment call. But how often have you seen a patient with subarachnoid hemorrhage have an emergent craniotomy? How often do low grade solid organ injuries fail if they’ve always had stable vital signs? Or even high grade injuries? The answer is, not often at all! So let them eat!
Bottom line: Unless your patient is known to be heading to the OR soon, or just had a laparotomy, the default trauma diet should be a regular diet!
I’m just putting the finishing touches on the next newsletter. It contains everything that you really want to know about Trauma in Pregnancy. Here are the contents:
- Predicting outcomes
- Tips & Tricks (for EMS and physicians)
- Peri-mortem C-section: when, with what, and how?
I’m going to release this issue to subscribers on Halloween. Everyone else can pick it up here on the blog about 10 days later.
If you want to get it as soon as it is released, please subscribe by clicking here! And you can pick up back issues when you follow the link, too!