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 of trauma:
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.
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 sixth law of trauma:
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.
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.
The Second Law Of Trauma
Your trauma patient is bleeding to death until you prove otherwise.
Obviously, there are a few uncommon exceptions to this rule. This includes sources of obstructive shock such as tension pneumothorax and tamponade. But by and large, you will find this law a solid one.
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.
After pursuing any discipline 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 arrhythmia and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab. It is far more likely the crash is causing these problems rather than an MI causing a crash.
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.
A patient who follows up in your trauma clinic with new complaints after a previous gunshot to the abdomen needs further clinical investigation, not just reassurance.
Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Injury can and does kill people more quickly that an MI or a stroke, especially if it was never suspected.
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.
It’s been five years since I published my Laws of Trauma, and it’s time to dust them off again. In the meantime, I’ve added a couple of new ones.
But before I start publishing them next week, I’d like to take a moment to share “McSwain’s Rules of Patient Care.” I met Norm McSwain when I was junior faculty at the University of Pennsylvania. As so many of his era were, he was larger than life. He was friendly, outgoing, animated, and a real champion for quality trauma care.
Norm was a skilled surgeon and teacher, but his achievements were felt far outside his home in Louisiana. He was an early member of the ACS Committee on Trauma, and was very involved in the development of the Advanced Trauma Life Support and Prehospital Trauma Life Support courses. He is credited with developing the original EMS programs in both Kansas, where he took his first faculty position out or residency, and in New Orleans, his home for the remainder of his life. He spent his career at the Charity Hospital there, weathering multiple political storms over the years, as well as the big one, Hurricane Katrina. He was instrumental in achieving Level I Trauma Center status for its replacement, Interim LSU Hospital.
Norm’s accomplishments are, as many of his contemporaries who have left us, too numerous to count. I certainly won’t try to recount them here. But it was his charm, his love for his charges, and his willingness to teach every trauma professional that will always be remembered.
I’ll leave you with his 18 rules of patient care. They are timeless, and will serve you well regardless of your degree and level of medical training.