All posts by TheTraumaPro

Medical Helicopter Crash – The Ultimate Distracted Driving

Yesterday, the NTSB released findings from an investigation of a medical flight that crashed in Mosby, Missouri in 2011. I’ve written about distracted driving before, but this is the worst example I’ve seen.

Apparently, the pilot was having a text conversation during the preflight check and missed the fact that the ship was low on fuel. Once enroute, he finally noticed the situation, but proceeded to pick up a patient for transport, planning on a refueling stop enroute to his destination.

But then he got involved in more texting, regarding his dinner plans for that evening. Think about it: texting while flying a helicopter means taking one hand off the collective control. He apparently believed that he did have enough fuel to get to his destination. Unfortunately, the ship, pilot, patient, and two medical personnel crashed a mile from their destination, within sight of the airport.

Teenagers know texting is wrong, but they believe that they know the way to do it safely. New information shows that adults are just as guilty as their children, but they do it anyway. Airline pilots got distracted working on their laptops in the cockpit, and overflew the Minneapolis airport by several hundred miles a few years ago. Everyone is doing it and they know it’s wrong!

Bottom line: There are no easy solutions, and laws are having only limited effect. For situations like this one, the easiest way to deal with it is to expand the team concept in the aircraft. The crew can’t be arbitrarily divided into medical and flight personnel (pilot) anymore. It seems that these days the nurse/medic/docs on board not only need to tend to their patient, but they need to look after the pilot as well. For everyone’s safety!

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Reference: Numerous news items on April 9, 2013. See CNN content here.

Pop Quiz: Jet Ski Injury

This post is for my readers located near large bodies of water!

Personal watercraft use exploded a decade ago, and they are still heavily used for recreation and vacation fun. However, speed and people don’t always mix well. Here’s an interesting case to ponder.

An 18 year old woman was the rear passenger on a jet ski traveling at a high rate of speed (of course). She fell off and was plucked out of the water by the driver. After riding for another 30 minutes, they headed to shore. A short while later, she began experiencing vague lower abdominal discomfort. This slowly progressed throughout the afternoon, becoming more severe.

She presents to your ED, looking uncomfortable and slightly ill. Here are some questions to ponder:

  • What injuries are you concerned about?
  • What diagnostics are appropriate?
  • If surgery is required, what are the appropriate approaches and procedures?

Please comment below, or tweet your thoughts. Answers tomorrow!

The First Law Of Trauma

Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.

The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Some examples:

  • An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
  • A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
  • A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down. 

Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.

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The Newest Trauma MedEd Newsletter Is Available!

The March newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Protocols. You’ll need a QR code reader if you want to download to your mobile device. Or just use the web URLs provided to download to your desktop/notebook.

In this issue you’ll find articles on:

  • Why are protocols important?
  • ED extubation protocol
  • CIWA protocol
  • TBI screening
  • Blunt trauma imaging protocol

Subscribers had the newsletter emailed to them over the weekend. If you want to subscribe (and download back issues), click here.

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Download the newsletter here!

Blunt Vertebral Artery Injury

Following up on yesterday’s post, I’ll deal with vertebral artery injuries today. These injuries are uncommon, making them hard to study and develop management recommendations. The literature suggests that about 1% of blunt trauma patients may sustain one of these. Most commonly, the method is motor vehicle crash, and just about any mechanism (hyperflexion, hyperextension, distraction injury, and facet fractures). Fracture of C1-3 has a higher association with the injury.

What is the natural history of this injury? If treated, 67% of occluded vessels recanalize, and 90% of stenotic arteries return to normal caliber. About 15% of untreated injuries will suffer a stroke. As seen in the paper cited yesterday, a good number of these are present on patient arrival and are nonpreventable. But the key issues are identifying an injury in the first place, and treating appropriately. Unfortunately, these are not straightforward.

Although the gold standard for detecting this lesion is digital subtraction angiography, no one does this in acute trauma patients anymore. CT angiography is well established, and the sensitivity rate approaches 99%. The main question is when to get it. To see my hospital’s interpretation of the literature, download our blunt imaging protocol below.

Treatment options include anticoagulation / antiplatelet therapy and endovascular therapy. There is much more experience with the former, but it can’t be used in patients at risk for bleeding (e.g. severe TBI). Unfractionated heparin is good for in-hospital use because it easily reversed. Longer term, anti-platelet agents are preferred. Aspirin is cheaper than clopidagrel, and no study has shown convincing superiority of one over the other. Determining whether endovascular stenting or embolization is necessary requires consultation with a neurosurgeon and interventional radiologist. The decision making is complex and not laid out in the literature. It’s flying by the seat of one’s pants, at best but can be a valuable adjunct.

Followup imaging is suggested to help determine when and if anti-platelet therapy can be discontinued. The best timing for these studies has not been worked out, but since these lesions tend to evolve over 7-10 days, any time after 2 weeks should be appropriate.

Bottom line: This is a tough topic because of the scarcity of good data, which in turn is due to the rarity of the injury. I believe that finding the lesions with good screening criteria offers the best chance of preventing complications such as stroke. Choice of management is best done in collaboration with your neurosurgical and radiologist colleagues.

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