All posts by TheTraumaPro

The Two-Sheet Trauma Trick

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.

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Trauma Care And HIPAA Demystified

HIPAA

There is a lot of confusion and misinformation out there regarding HIPAA (Health Insurance Portability and Accountability Act). This law was enacted in 1996 with the intent of protecting the health insurance benefits of workers who lose or change their jobs, providing standards for electronic health care transactions, and protecting a patient’s sensitive health information. This last part has caused much grief among trauma professionals.

It is commonplace for a trauma patient to require the services of many providers, from the initial prehospital crew, doctors and nurses at the initial hospital, yet another ambulance or aeromedical crew, professionals at a receiving trauma center, rehab or transitional care providers, and the patient’s primary physician to name a few. Unfortunately, because there can be significant financial penalties for violating the HIPAA privacy guidelines, providers are more likely to err (incorrectly) on the side of denying information to others outside their own institution.

All of the people mentioned above are considered “covered entities” and must abide by the HIPAA Privacy Rule. This rule allows us to release protected information for treatment, payment and “health care operations” within certain limits. The first and last items are the key provisions for most trauma professionals.

Treatment includes provision, coordination and management of care, as well as consultations and referrals (such as transferring to a trauma center). Think of this as the forward flow of information about your patient that accompanies them during their travels.

Health care operations include administrative, financial, legal and quality improvement activities. These quality improvement activities depend on the reverse flow of information to professionals who have already taken care of the patient. They need this feedback to ensure they continue to provide the best care possible to everyone they touch.

Bottom line: Trauma professionals do not have to deny patient information to others if they follow the rules. Obviously, full information must be provided to EMS personnel and receiving physicians when a patient is transferred to a trauma center. But sending information the other way is also okay when used for performance improvement purposes. This includes providing feedback to prehospital providers, physicians, and nurses who were involved in the patient’s care at every point before the transfer. The key is that the information must be limited and relevant to that specific encounter.

Feedback letters and forms, phone conversations and other types of communications for PI are fine! But stay away from email, which is not secure and is usually a violation of your institutional privacy policies.

Always consult your hospital compliance personnel if you have specific questions about HIPAA compliance.

Reference: HIPAA Privacy Rule

Pop Quiz: The Answer

Tip of the hat to John Greenwood, who got the correct answer to this problem case. The CT shows that the patient developed a pseudoaneurysm in the spleen (A) with a fistula to the splenic flexure of the colon (B). This resulted in a sentinel bleed that caused an episode of hematochezia.

Could this have been detected at the initial presentation? No, since the pseudoaneurysm was not seen on the initial CT. There is little support in the literature for serial evaluation by CT, but this may be the one case (in a billion!) where it may have been useful. This should not be enough to change your ordering behavior, though.

How does the pseudoaneurysm result in a fistula to the colon? That’s a good question. Pseudoaneurysms typically grow until they rupture, resulting in troublesome bleeding. My suspicion was that there was also a colon injury at the splenic flexure due to the handlebar injury mechanism which allowed this process to develop. Otherwise it’s hard to envision a pseudoaneurysm burrowing through all layers of a normal colon for no real reason.

What’s the proper treatment? In my mind, only exploration with splenectomy and colon resection/repair is acceptable. Embolization of the spleen may reduce the likelihood of future bleeding, but there is still a potential abscess in the area and it’s very difficult to predict what it will do over time. 

Reference: Splenocolic fistula after nonoperative management of splenic rupture. Trauma 15(1):86-90, 2013.

Pop Quiz: Hints

No correct guesses yet, but some good tries! Remember, this was a 16 year old male who crashed a motorcycle and sustained liver and spleen injuries. A month after successful nonoperative management, he presents with a single episode of hematochezia. 

Here’s a CT scan taken during the second ED visit:

What’s the problem? Any way to have detected it sooner? What to do now?

Comment or tweet your answers!