All posts by TheTraumaPro

ED Thoracotomy Survey: Read The Answers! (Rest of the World)

Last time, I posted summary info for ED thoracotomy on US trauma centers. Here’s a rundown of the answers provided by international respondents. A few duplicates from the same hospitals have been merged into single answers for them. The total number of international centers for the tables below is now 43.

Level of trauma center (or equivalent)

Level I 22
Level II 8
Level III 6
No level 7

 

How many ED thoracotomies are performed per year at your hospital?

A few per year (<6) 30
About every month (6-15) 6
A couple of times a month (16-30)4 4
About every week (31-52) 2
Not specified 1

 

What type of trauma do you perform ED thoracotomy for?

Both blunt and penetrating 22
Penetrating 17
Blunt 4

 

Do you use a practice guideline for ED thoracotomy?

Yes 17
No 16
I’m not sure 10

 

Do you use REBOA in your ED?

No 32
Yes 9
I’m not sure 2

 

And now for the questions you’ve been waiting for!

Who could perform ED thoracotomy at your hospital? (n=149)

Surgeon 39
Emergency physician 25
Surgical resident / fellow 15
Emergency medicine resident 7
Intensivist 1
ED intern / medical officer 1
No one 1

 

Who usually performs ED thoracotomy at your hospital? (n=149)

Surgeon 32
Emergency physician 15
Surgical resident / fellow 9
Emergency medicine resident 1
Thoracic surgeon on call 1
Trauma team leader 1
Never done one 1

 

ED Thoracotomy Survey: Read The Answers! (US)

Again, thanks for all who submitted their survey answers. Here’s a rundown of the answers provided by US respondents. A few duplicates from the same hospitals have been merged into single answers for them. Total number of US centers for the tables below is 149.

Level of trauma center

Level I 83
Level II 37
Level III 15
Level IV 1
Level V 2
Seeking verification/designation 1
No level 10

 

How many ED thoracotomies are performed per year at your hospital?

A few per year (<6) 83
About every month (6-15) 35
A couple of times a month (16-30) 23
About every week (31-52) 8

 

What type of trauma do you perform ED thoracotomy for?

Both blunt and penetrating 79
Penetrating 64
Blunt 5

 

Do you use a practice guideline for ED thoracotomy?

Yes 86
No 47
I’m not sure 15

 

Do you use REBOA in your ED?

No 88
Yes 58
I’m not sure 3

 

And now for the questions you’ve been waiting for!

Who could perform ED thoracotomy at your hospital? (n=149)

Surgeon 145
Emergency physician 109
Surgical resident / fellow 93
Emergency medicine resident 66
APP (PA, NP) 2 at one Level I and one Level V
Family physician 1 at one Level V
Family medicine resident 1 at one Level V

 

Who usually performs ED thoracotomy at your hospital? (n=149)

Surgeon 115
Emergency physician 25
Surgical resident / fellow 69
Emergency medicine resident 17
Never done one 3
Family physician or family nurse practitioner 1 at one Level V

 

Who usually performs ED thoracotomy at your hospital? (By trauma center level)

Level I (n=83) II (n=37) III (n=15)
Surgeon 64 35 11
Emergency physician 8 3 6
Surgical resident 63 4 1
Emergency medicine resident 12 1 2
No one 0 0 1

 

Join me tomorrow when I review the international data!

Coming Tomorrow: ED Thoracotomy Survey Results

The data is in!

Thanks to everybody (all 200+ of you) who participated in the ED thoracotomy survey over the past month. I’m currently compiling the results and will post them here over the next two days.

Here is a summary of who responded:

  • 50% were emergency medicine physicians or residents
  • 22% were surgeons or surgical residents
  • 15% were nurses
  • 6% were advanced practice providers such as NPs or PAs

And where were they located?

As you can see, the vast majority (167) were from the United States. Australia, Canada, and Denmark added another 18, and a variety of other countries contributed the remaining 27 surveys.

Over the next two days, I’ll focus on the US data, then look at the results from the rest of the world.

Again, thanks for contributing!

 

Guidelines for Consultants to the Trauma Service

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in writing (paper or EMR) in a timely manner.
  • If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
  • We round at specific times every day and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.

Consultant Gives An Unusual Recommendation: What Would You Do?

I know this has happened to most of you at one point or another:

One of your trauma patients sustains an injury outside of your area of expertise. You engage a consultant to evaluate that condition and manage it. They do so, and it requires some type of invasive procedure. They return from the procedure, and as you are rounding on the patient, you find the consultant has ordered a medication that you have not seen ordered for that procedure before.

What would you do? You are now in an interesting place. Do you discontinue the order? Call up the consultant and ask, what the heck? Might you poison your relationship with them in the process? And what is the impact on your patient?

Lots of questions, but here is what I recommend:

  • Hit the lit! Always assume that they might know something you don’t. They are an expert in their field for a reason, so give them the benefit of the doubt. Thoroughly review the literature to see if this is an approved new practice. But remember, a single interesting paper should never be enough to change your (or their) practice. There needs to be a sufficient body of literature showing that the practice is sound.
  • Talk to the consultant. Now that you are armed with the current thinking, ask them what they were thinking! Let them explain their rationale. Since you have already looked at the available data, you will be able to ask appropriate questions and deflect answers like, “well that’s how we did it where I trained.”
  • Change the orders. Assuming the order was not sound, it’s time to undo the ones that started this entire debate. Get rid of them now so you’re not stepping on any toes. However, if you believed that the order/medication would have been potentially harmful, don’t wait. You should have done it even before the first step!
  • Disseminate the info. Make sure that all of your partners are aware of the issue and the correct course of action (or orders). And send a note to the consultant group summarizing the discussion so none of your consultant’s partners make the same mistake again.

Tomorrow, a set of guidelines to give all of your consultants to make sure they behave appropriately and interface will with the trauma service.