All posts by TheTraumaPro

The 30:60 Rule For Interventional Radiology

Interventional radiology (IR) can be a very helpful adjunct to the evaluation and management of trauma patients. I’m going to talk specifically about using it for blunt trauma today because the use in penetrating trauma can be a little more nuanced.

For blunt trauma, IR is used primarily to stop bleeding. In a smaller subset of patients, this tool is used to evaluate pulse deficits. There are two basic principles that apply in either case, and I’ve wrapped them up into a single concept: the 30:60 rule for interventional radiology. 

Of course, the second law of trauma still applies: hypotensive patients cannot leave the ED to go anywhere but the OR. Once you make sure you are not violating that one, you can start the process of going to IR.

The two portions of the rule are times: the time for the IR team to arrive to start the evaluation, and the maximum time allowed for them to succeed, hence the 30:60 numbers.

The maximum acceptable time for the patient to wait until the IR team is ready for them is typically 30 minutes. US trauma center verification requires a reasonable arrival time frame, and the vast majority of hospitals have a 30 minute expectation if the team is not already in place. This response time needs to be monitored by the trauma performance improvement program (PI) and addressed if it ever exceeds the limit.

The second number is the maximum time the radiologist is given to be successful. Like other physicians, radiologists like to do a good job and finish the work they start. If they find a particularly tortuous splenic artery to navigate, they will persist at trying to get through it in order to do a selective embolization and kill the smallest piece of spleen possible. Unfortunately, this takes time and radiation (lots). And a bleeding patient is running out of time.

The good thing is that there are surgical alternatives to most of the tasks the radiologist is working on. True, some are much more difficult surgically, like managing a shattered liver or dealing with a bleeding pelvis. In those cases, I may let the interventionalist work a little longer while I keep up with blood transfusions and monitor patient status.

Bottom line:

  • Expect a 30 minute response time from the IR team
  • Let the radiologist know they have about 60 minutes to succeed. If it looks like they can’t make that, have them go to plan B (e.g. main splenic artery embolization instead of selective)
  • Make sure an experienced trauma physician is watching the patient for decompensation and is managing fluids and blood products (no pressors!)
  • If the patient decompensates at any point, they are done in IR and must proceed to OR

Next TraumaMedEd Newsletter Available Soon!

The March issue of TraumaMedEd is ready to go! This issue is devoted to protocols. 

Included are protocols for:

  • Anticoagulation reversal
  • TBI screening
  • Chest tube management
  • Solid organ injury management
  • And more!

Be sure to have a good QR code reader for easy retrieval. Otherwise, warm up your fingers so you can enter URLs to download the protocols.

Subscribers will get the issue delivered Saturday. It will be available to everybody on the Tuesday blog post.

Check out back issues, and subscribe now! Get it first by clicking here!

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).