Trauma service staffing is important to maintaining trauma center status. Teaching centers in the US have been grappling with resident work hour rules, and non-teaching centers have always had to deal with how to adequately staff their trauma service. What is the impact of staffing a trauma center with midlevel practitioners (MLPs) such as physician assistants and nurse practitioners?
A state designated Level I trauma center in Pennsylvania retrospectively examined the effect of adding MLPs to an existing complement of residents on their trauma service. They examined the usual outcomes, including complications, lengths of stay, ED dwell times and mortality.
Here are the more interesting factoids:
ED dwell time decreased for trauma activations and transfers in, but it increased for trauma consults. Of note, data on dwell times suffered from inconsistent charting.
ICU length of stay decreased significantly
Hospital length of stay decreased somewhat but did not achieve significance
The incidence of most complications stayed the same, but urinary tract infection decreased significantly
There was no change in mortality
Bottom line: There is a growing body of literature showing the benefits of employing midlevel providers in trauma programs. Whereas residents may have a variable interest in the trauma service based on their career goals, MLPs are professionally dedicated to this task. This study demonstrates a creative and safe solution for managing daily clinical activity on a busy trauma service.
Reference: Utilization of PAs and NPs at a level I trauma center: effects on outcomes. J Amer Acad Physician Assts, July 2011.
Traumatic brain injury (TBI) frightens and confuses most trauma professionals. The brain and its workings are a mystery, and there is very little real science behind a lot of what we do for TBI. One thing that we do know is that intracranial hypertension is bad. And another is that we do have some potent drugs (mannitol, hypertonic saline) to treat it emergently.
So if we can “dry out” the brain tissue on a moment’s notice and drop the ICP a bit with a hit of sodium, doesn’t it stand to reason that elevating the sodium level constantly might keep the brain from becoming edematous in the first place? Many neurosurgeons buy into this, and have developed protocols to maintain serum sodium levels in the mid-140s and higher. But what about the science?
A nice review was published in Neurocritical care which identified the 3 (!) papers that have promoted this practice in humans with TBI. In general, there was a decrease in ICP in the patients in the cited papers. Unfortunately, there were also a number of serious and sometimes fatal complications, including pulmonary edema and renal failure requiring hemodialysis. These complications generally correlated with the degree of hypernatremia induced. Papers were also reviewed that involved patients with other brain injury, not caused by trauma. Results were similar.
Bottom line: There is no good literature support, standard of care, or even consensus opinion for prophylactically inducing hypernatremia in patients with TBI. The little literature there is involves patients with severe TBI and ICP monitors in place. There is nothing written yet that justifies the expense (ICU level care) and patient discomfort (frequent blood draws) of using this therapy in patients with milder brain injury and a reliable physical exam. If you want to try out this relatively untried therapy, do us all a favor and design a nice study to show that the benefits truly outweigh the risks.
And if you can point me to some supportive literature that I’ve missed, please do so!
Induced and sustained hypernatremia for the prevention and treatment of cerebral edema following brain injury. Neurocrit Care 19:222-231, 2013.
Continuous hyperosmolar therapy for traumatic brain injury-induced cerebral edema: as good as it gets, or an iatrogenic secondary insult? J Clin Neurosci 20:30-31, 2013.
Continuous hypertonic saline therapy and the occurrence of complications in neurocritically ill patients. Crit Care Med 37(4):1433-1441, 2009. -> Letter to the editor Crit Care Med 37(8):2490-2491, 2009.
I always tell my trainees that “your patient is bleeding to death until you can prove otherwise.” Sometimes bleeding is obvious in our trauma patients and sometimes it isn’t. The usual routine for assessing major trauma patients involves a blood draw, with a high priority on obtaining a specimen for the blood bank. But most centers also get standard analyses on the blood, including CBC, lytes, etc.
But remember, a blood draw is a snapshot. And it’s a snapshot of values that change relatively slowly. This means that you can get suckered into believing that your patient is okay because one set of labs looked pretty normal. And it’s impractical (and uncomfortable) to get labs frequently with repeated needle sticks.
Masimo, a medical equipment manufacturer, has added something extra to the pulse oximeter that you are already familiar with. Using the usual clip-on finger probe, it measures arterial oxygen saturation, pulse rate, perfusion index, and total hemoglobin.
I wrote about this device a year ago after an abstract was presented at EAST. The final paper from the University of Arizona – Tucson has now been published, and here are the updated factoids:
525 patients were spot-checked, with a success rate of 86%
Spot-check failures were due to nail polish or soot on the nails, sensor fit problems (only one size was available in the study), placement problems due to other imaging equipment, or patient agitation
173 (38%) of patients had a Hgb <= 8
The mean difference between spot-check and blood draw results was only 0.3 g/dL (!)
Sensitivity was 95%, accuracy 76%
Bottom line: This is an interesting new tool for acute trauma care. The only downside that I see is that we may lose sight of the fact that hemoglobin values lag behind as an indicator of true blood volume in rapidly bleeding patients. We mustn’t be fooled into thinking that everything is fine just because a number is normal. There’s still room for common sense! And don’t start monitoring serial hemoglobins willy nilly in solid organ injury just because you can. You still don’t need it!
Hypothermia is always a concern in trauma patients. Even the simple act of completely exposing your patient in the trauma room facilitates it. How do trauma professionals balance the need to see everything with the equally important need to keep the patient warm?
The natural reaction is to cover them up. Sheets and warm blankets are the usual tools. But I always marvel that, as soon as the blanket goes on, there’s always a need to examine something or do some procedure. Look at a wound. Insert a urinary catheter. And every time this happens, the blanket comes off.
Here’s a clever way to deal with this problem. Don’t use just one sheet or blanket. Use two! Fold each one in half, so they are each half-length. Place one on the top half of the patient, the other at the bottom, overlapping slightly at the waist. If you need to look at an extremity, fold the blanket that covers it over from right to left (or left to right) to uncover just the area of interest. To insert a urinary catheter, just open the area at the waist, moving the top sheet up a little, the bottom down a little.
Bottom line: Keep your patient toasty! Use the two-sheet (or warm blanket) trick to avoid hypothermia. Remember, patient temperature begins to drop as soon as the clothes come off! And I don’t recommend the use of one-piece inflatable warming blankets (e.g. Bair Hugger) until the work in the ED is complete, because the whole thing has to be removed every time you need meaningful access to the patient.