All posts by TheTraumaPro

Ever Wonder Where The Golden Hour Came From?

Everywhere you turn in the trauma and EMS world, you run into the concept of the “golden hour.” Basically, it refers to the idea that it’s important to get an injured patient to definitive care promptly, or mortality begins to rise. It has been used to justify a lot of what we do in trauma care and trauma systems. But where did this come from? And is it true?

The BTLS course attributes the term to R Adams Cowley from the ShockTrauma Center in Baltimore. Unfortunately, no references are given. A biography of Cowley entitled Shock-Trauma names him the author of the term, basing it on dog research. No references were given.

A review of Cowley’s research reveals a few tidbits. A case series of patients implies that speed is good, but does not analyze time to definitive care. It does reference older work by other authors, but once again, no relationship between timing and outcome is evaluated.

A textbook edited by Cowley contains a reference to an article about “Cowley’s golden hour.” This article contains a statement that “patients are assumed to be dying and much of the golden hour has passed.” It goes on to state that the first 60 minutes after injury determines the patient’s mortality. It, in turn, refers to another of his earlier articles. This one states that “the first hour after injury will largely determine a critically injured person’s chance for survival.” No data or reference is given.

Bottom line: The concept of the “golden hour” has taken on a life of its own. Yes, it’s a good idea. And yes, there is some actual data to support it, although the quality is somewhat lacking. But this does point out the need to question everything, even some of our most deeply held beliefs. They are not always what they seem to be.

Reference: The Golden Hour: scientific fact or medical urban legend? Acad Emerg Med 8(7):758-760, 2001.

Obit: Eric R. (Rick) Frykberg

Sadly, Rick Frykberg passed away yesterday morning at the age of 63. He was the Chief of the Division of General Surgery at the University of Florida and Shands Hospital in Jacksonville, Florida. Rick was a Professor of Surgery and was a great educator and clinician. He did his internship at NYU Medical Center in New York, and completed his residency at the Medical University of South Carolina. From there he became a staff surgeon at the US Naval Hospital in Jacksonville. He then joined the faculty at the University Medical Center and stayed there for the rest of his career.

Rick was very active in the trauma community and was a member of AAST and EAST. He joined both organizations in 1988 (!), and was elected to the board of directors of EAST in 1996. From there he moved up and was elected president of the EAST in 2001. Rick generated a robust body of research, with much of it focused on the area he became known for, vascular injury. He also had interested in disaster medicine and breast surgery.

Rick will be missed by his family, colleagues, and trainees.

Trauma Coverage By Locum Tenens Surgeons

Trauma call coverage is not always easy to come by, especially at lower level trauma centers and in rural areas. Many centers come to rely on locum tenens surgeons to fill gaps in their call schedules. Unfortunately, this can create some headaches.

There is currently no trauma literature on this topic. Other disciplines, most recently pediatric surgery, have some published suggestions (I hesitate to call them guidelines) on requirements and expectations based on the ACGME core competencies.

Here are some of the nuances that any trauma program needs to recognize if the use of locum tenens surgeons is being considered:

  • Board certification – This is a basic tenet of trauma center verification and should be absolutely required
  • Trauma CME – Make sure that all locums meet the CME or internal education program (IEP) requirement before they start
  • Core vs non-core surgeon – Locums are best designated a non-core surgeon so they are not required to attend multidisciplinary PI committee meetings (MDPI)
  • Dissemination of committee proceedings – Make sure that this is well-documented. Since these surgeons are not required to attend MDPI if they are non-core, they must be aware of all items discussed, particularly if it involves their care
  • Responsibility for quality issues – This is the most troubling aspect of using locums. It’s tough to hold one of these surgeons responsible for issues arising from their care if they have left and are never coming back. Make sure there is a mechanism to send feedback about their care even after they are gone for good. And document it well!

Bottom line: In my opinion, the use of locum tenens to cover trauma call gaps is a necessary evil. It should only be used until a more stable coverage pool is available. The management of quality issues in particular is much more difficult when using roving surgeons. If you must use them, use them wisely and only briefly.

Reference: Proposed standards for use of locum tenens coverage in pediatric surgery practices. J Pediatric Surg 48:700-703, 2013 (letter).

Repeat Imaging: What Good Is It?

I’ve written previously about how often imaging gets repeated once a trauma patient gets transferred to a trauma center (click here). There are many reasons, including clinical indications, need for advanced imaging (reconstructions), or lack of contrast. But at least 20% have to be repeated because the media is incompatible or not sent with the patient. Sounds like a problem, but is it a significant one?

A recent retrospective analysis of about 2,000 transfers to a Level I center looked at the reasons for repeat imaging and changes in outcome due to it. The paper found several interesting things:

  • Repeat imaging was more likely in more severely injured patients
  • Hospitals that transferred more patients to the trauma center tended to do more scans before transfer
  • Patients who had repeat imaging stayed in the ED longer waiting for definitive disposition
  • Repeat images did not improve outcomes (LOS, DC home, mortality)
  • A rough estimate of $354 more in charges was attributed to repeat imaging

Bottom line: Repeat imaging is wasteful, expensive and increases time in the ED. And don’t forget about the radiation exposure. With all the emphasis on pushing hospitals to use an electronic medical record, there needs to be a similar push to standardize methods for transferring radiographic images between hospitals to address the problem of repeat imaging.

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Reference: Repeat imaging in trauma transfers: A retrospective analysis of computed tomography scans repeated upon arrival to a Level I trauma center. J Trauma 72(5):1255-1262, 2012.

Clearing The Cervical Spine – Part 2

Yesterday, I wrote about our algorithm for clearing the cervical spine in an adult with normal mental status. Today, I’ll go over our protocol for obtunded patients. You can download it using the link below.

Here are the key points:

  • MRI is the cornerstone of definitive evaluation of the ligaments once a normal CT spine study has been obtained
  • There is no time limit for getting the MRI
  • Spondylosis or degenerative changes are a red flag if MRI is not possible; the spine service must always be involved if either of these are present

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