All posts by TheTraumaPro

Mystery Diagnosis: The Answer

A young male suffered blunt torso trauma when struck by a car. Many of you sent your guesses for what is shown in the image below:

This patient sustained a traumatic pneumatocele. It is an uncommon injury in blunt trauma, and can also be caused by penetrating injury. It’s essentially a complicated laceration that fills with air leaking from torn airways (alveoli or bronchi of various sizes). 

There is usually some focal hemorrhage around the injury, which looks (and is) a pulmonary contusion. The hallmark is the bubble (or bubbles) of air that form in the area of the injury. Frequently, these can be seen on chest xray as well, although CT is much more sensitive. They are more commonly located near the pleural surface of the lung in blunt trauma, because this is the area of maximum impact. When present, they are often situated very close to a rib fracture.

Generally, these injuries do not require any specific management. They slowly heal over time, but it may take months for them to completely resolve.

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Mystery Diagnosis

Here’s a not so common trauma problem. See if you can figure it out.

A 30 year old male was crossing the street after leaving a bar(!). He failed to notice a speeding SUV, which promptly struck him and sent him flying. He was evaluated as a trauma activation at your hospital, and you scanned his torso. You find this in his chest:

What is it, and what do you need to do about it?

Reply, Tweet, or email your ideas. Answers tomorrow!

Nurses: Stop The Insanity! When The Doc Won’t Listen

“Insanity: doing the same thing over and over again and expecting different results.”

– Albert Einstein

This post applies specifically to nurses. I know it’s happened to you. Your patient is having a problem. You do a little troubleshooting, but you feel that a doctor needs to know and possibly take some action. So you page them and duly note it in the medical record. No response. You do it again, and document it. No response. And a third time, with the same result.

And now what? Call someone else? Give up and hope the patient improves? 

What if the doctor on call is a known asshole? Are you even reluctant to call in the first place? Do you delay as long as you possibly can?

Believe it or not, I’ve seen many chart review cases over the years where this situation does arise. And every once in a while, the patient actually dies. Sometimes this is directly related to the lack of intervention, but sometimes it just sets the ball rolling that eventually leads to patient demise days or weeks later.

What’s the answer? We all want to provide the best care possible for our patients. But sometimes social factors (or pager malfunctions) just get in the way. Here’s how to deal with it.

Every hospital / nursing unit needs to have a procedure for escalating patient care calls to more advanced providers. When one of your patients develops a problem, you usually have a pretty good idea of what the possible solutions are. So call/page the proper person (PA/NP/MD) who can provide that solution. If they don’t give you the “right answer”, then question it. They are not all-knowing. 

If they give you a good explanation, go with it, but keep your eye on your patient’s progress. If they can’t explain why they are giving you the wrong answer, suggest they check with someone more senior. And if they don’t want to, let them know that you will have to. Consider no answer the same as a wrong answer.

Don’t stop going up the chain of command until you get that right answer, or an explanation that satisfies you. The hard part here is going up the chain. You may not be comfortable with this. But you do have resources that can help you that have more authority (nurse manager, supervisor, etc). If they, too, are uncomfortable, then your hospital has much bigger problems (unhealthy workplace). 

Example: trauma unit nurses at my hospital will call the first year resident first, then escalate to the junior and/or chief residents. If they don’t do the right thing, the in-house trauma attending gets the call. If they don’t handle it, then the trauma medical director (me) gets called. And, of course, I always do the right thing (chuckle). And our nurses know that the surgeons support them completely, since this facilitates the best patient care. The residents and PAs are educated about this chain of command when they first start on the trauma service, and it makes them more likely to choose the “right answer” since they know the buck may not stop with them.

Hypotensive Patients And CT Scan – Part 2

Yesterday, I went on a rant about taking hypotensive patients to CT. The bottom line is that this is a generally bad idea. However, we all know that there are no absolutes, especially in trauma.

So yes, there are two cases where one could justify taking a hypotensive patient to CT scan. Here they are:

  1. You believe that your patient has a catastrophic brain injury which is responsible for the hypotension. You would like CT confirmation so you can begin to withdraw support and terminate any other interventions.
  2. Your patient has sustained a cervical spinal cord injury and has neurogenic shock. You have started fluid resuscitation and are considering a pressor to normalize blood pressure, but would like to continue your diagnostic routine.

But before you can even consider leaving your resuscitation room, you must ensure that there is no other source of hypotension. This means getting chest and pelvic xrays to look for hemothorax or fractures. It means getting a good FAST exam to make sure there is no significant hemoperitoneum. It also means making sure that any fractures are properly splinted and there is no uncontrolled external bleeding.

You can only go to CT scan once all of these other potential bleeding sources have been ruled out. If in doubt, you must proceed to OR to either stop the bleeding or prove that it does not exist.

Are there any other reasons to take one of these patients to CT that you can think of? If so, leave comments or tweet!

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