And now, the last one in the series (for now).
You’ve just received a young male who had been stabbed under his right arm in your emergency department. He’s awake, talking, and very friendly. He met your trauma activation criteria, so you are cruising through the full evaluation. Lines in, blood drawn, clothes off. He wonders aloud if all this is really necessary.
Then, on FAST exam, you see it. A pericardial stripe that looks like a mix of liquid and clotted blood. Your colleague steps in and verifies the exam. But vital signs are normal, the patient is fine.
What next? CT of the chest to further define this? A formal echo to confirm? Your surgeon says no, we’re going to the OR, now! Reluctantly, you package the patient and send him on his way. In the OR, the anesthesiologist takes his time, putting in an arterial line, asking the patient unrelated questions. A thoracotomy? Really? The patient remains awake and alert through all of this.
So here’s the fourth law:
Even awake, alert, and stable patients die. And it hurts that much more when they do.
Bottom line: You know the diagnosis in this case. And you know what needs to be done. But the awake and alert patient fools us. Fakes us out. Somehow, we equate the ability to talk intelligently with being fine. But evil things can be going on inside that don’t rear their ugly head until it’s too late. Don’t get suckered! Believe your exam, not what the patient thinks they are telling you.
Other Laws of Trauma:
Trauma patients don’t always behave the way we would like. They continually surprise us, sometimes for the better when they recover more quickly and completely than we thought. But sometimes it’s for the worse. They occasionally crash when we think everything is going so well.
The crashing patient is in obvious need of help and most trauma professionals know what to do. But then there’s the hypotensive patient. The BP just dropped to 84, and it’s not budging. Many don’t see this for what it is: a slow motion crash. And they want to do things they wouldn’t think of doing to a crashing patient. Like go to CT, do some more stuff in the ED because that BP cuff just has to be wrong, or call interventional radiology and wait for 45 minutes.
But here’s the thing:
The only place an unstable trauma patient can go is to the OR.
Bottom line: By definition, an unstable trauma patient is bleeding to death until proven otherwise (the second law, remember?). Radiation can’t fix that. Neither can playing around in the resuscitation room, unless the bleeding is spraying you in the face. The surgeon needs to quickly figure out which body cavity is the culprit, and address it immediately. And the only place with the proper tools to do that is an operating room.
Other Laws of Trauma:
There are two broad categories of things that kill trauma patients. No, I’m not talking about violent penetrating injury, falls, car crashes, or any other specific mechanisms. I am referring to the end events (on a macro scale) that take their lives.
These two basic killers are: hemorrhage and brain injury. The vast majority of the time, a dying trauma patient has either suffered a catastrophic brain injury, or has ongoing and uncontrolled bleeding.
Here’s the law:
Your trauma patient is bleeding to death until you prove otherwise.
Bottom line: Since there is little we can do above and beyond the basics in the ED for severe brain injury, your focus must be on hemorrhage. There are lots of things we can do about that, and the majority involve an operating room. Always assume that there is a source of hemorrhage somewhere, and it just hasn’t shown itself yet. There can be no rest until you prove that the source does not exist. And hopefully, you do that very, very quickly.
Other Laws of Trauma:
Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.
The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.
- An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
- A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
- A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.
Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.
Other Laws of Trauma:
What are common sources of malpractice complaints against nurses? The most common event is medication error. Most people worry about common errors like wrong dose, wrong drug, and wrong route of administration. But one less commonly considered drug-related responsibility is assessment for side effects and toxicity of medications administered.
Other common reasons include failure to adequately monitor and assess the patient, and failure to supervise a patient that results in harm. Significant changes in patient condition must be reported to the responsible physician. However, doing so does not necessarily get the nurse off the hook. If the physician’s response leads the nurse to believe that they have misdiagnosed the problem or are prescribing an incorrect drug or course of action, the nurse is obligated to follow the chain of command to notify a nursing supervisor or other physician of the event.
And finally, one of the most common issues complicating malpractice cases of any kind is documentation. Lawsuits must typically be filed within two years of the event that caused harm. Once that occurs though, several more years may pass before significant action occurs. Collection and review of documentation, identification of experts, and collection of depositions takes time. And unfortunately, our memories are imperfect after many years go by. Good documentation is paramount! “Work not documented is work not done,” I always say. And poor documentation allows attorneys to make your good work look as bad as they want and need it to.
Reference: Examining Nursing Malpractice: A Defense Attorney’s Perspective. Critical Care Nursing 23(2):104-107, 2003.