Alcohol and fireworks again?
Alcohol and fireworks again?
Alcohol and fireworks don’t mix!
“Feed a fever, starve a… trauma patient?”
Maybe it’s just my hospital. But I suspect it happens at yours, too. It always seems that when a trauma patient is admitted, someone is trying to starve them. The default diet order seems to be “nil per os” (NPO). But why?
Let’s say a patient with a blunt injury to the spleen is admitted to the trauma center. They have stable vital signs, so they’re started on a nonoperative management protocol. Nonoperative. So why not let them eat? More than 95 out of 100 are not going to the operating room.
But they might, you say. Well first of all, they are even less likely to fail in the next 6 hours (the time interval US anesthesiologists like to use, but that’s another post). So their stomach will be reasonably empty if they do manage to need an operation. And I would say that anesthesiologists at trauma centers are experts at putting people with full stomachs to sleep. It seems that every trauma patient that I CT scan has just eaten.
What about a patient with a stab to the abdomen that doesn’t look like it fully penetrated, but you want to observe them for 12 hours or more? NPO. But what’s the point? Once again, they might need to go to the OR, right? Well, if they actually do have an injury, I want them to show me sooner rather than later. I want to stress them. I want symptoms if they have a hole in their intestine. So I let them eat.
Bottom line: The default diet in nearly any trauma patient should be “regular.” The exceptions are patients who have just come out of abdominal surgery, and those who are known to be going to OR for any reason in the next 6 hours or so. Patients who are postop from non-abdominal surgery can resume their regular diet as soon as they feel up to it. And children should almost never be made NPO unless they are definitely scheduled for surgery. They (and their parents) don’t tolerate it too well.
The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?
Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.
This is one of those rules that seems so obvious. But you would be surprised how many times it’s ignored. Here’s just one example that can go wrong in so many ways:
How this can go wrong:
And the list goes on. And this is just one of a zillion possible tests that are ordered every day. In this example, looking at the image is simple in this day and age of having PACS viewers everywhere. However, many tests are not available for hours (coags), or are actually done at a later time (morning hemoglobin). This means more opportunities to miss significant results, and although they may not be as life-threatening as my trauma example, failure to check them can still cause significant problems.
Bottom line: Always review the result of every test you order, on every patient. In this age of shift work and work hour restrictions, a good hand-off to other trauma professionals is very important. You must make sure that somebody sees that result in a timely manner soon after it is available.
Corollary: If you really don’t need to see that result (i.e. it’s not going to change your care anyway), you shouldn’t have ordered the test!
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