All posts by TheTraumaPro

PAs and NPs In Level I Trauma Centers

Trauma service staffing is important to maintaining trauma center status. Teaching centers in the US have been grappling with resident work hour rules, and non-teaching centers have always had to deal with how to adequately staff their trauma service. What is the impact of staffing a trauma center with midlevel practitioners (MLPs) such as physician assistants and nurse practitioners?

A state designated Level I trauma center in Pennsylvania retrospectively examined the effect of adding MLPs to an existing complement of residents on their trauma service. They examined the usual outcomes, including complications, lengths of stay, ED dwell times and mortality. 

Here are the more interesting results:

  • ED dwell time decreased for trauma activations and transfers in, but it increased for trauma consults. Of note, data on dwell times suffered from inconsistent charting.
  • ICU length of stay decreased significantly
  • Hospital length of stay decreased somewhat but did not achieve significance
  • The incidence of most complications stayed the same, but urinary tract infection decreased significantly
  • There was no change in mortality

Bottom line: There is a growing body of literature showing the benefits of employing midlevel providers in trauma programs. Whereas residents may have a variable interest in the trauma service based on their career goals, MLPs are professionally dedicated to this task. This study demonstrates a creative and safe solution for managing daily clinical activity on a busy trauma service.

Reference: Utilization of PAs and NPs at a level I trauma center: effects on outcomes. J Amer Acad Physician Assts, July 2011.

Pulmonary Contusion After Sports Injury

Most pulmonary contusions occur after diffuse, high energy blunt trauma like a fall or car crash. Occasionally, pulmonary injury can occur after a much more focal injury like an impact during sports. This may occur due to direct impact from another player, or from a rapidly moving object like a ball or puck. Today, I’ll focus on the latter, impact from a fast-moving object.

Typically, the athlete will complain of pain at the area of impact and some degree of breathing impairment. This is usually due to musculoskeletal pain, rib fracture or involuntary splinting. It is possible to develop pneumothorax or hemothorax, especially if a rib is fractured. At some point, hemoptysis may be present. This is pathognomonic for the presence of a pulmonary contusion.

Any athlete with more than mild to moderate pain, or any physical exam findings other than tenderness, should be more fully evaluated. Here are some important tips:

  • The only imaging required is a two view conventional chest xray. This will identify significant pneumothorax, hemothorax or contusions that require additional management.
  • Chest CT is not indicated. It does not change management.
  • Use your typical algorithms for managing hemothorax and pneumothorax
  • A pneumatocele visible on the xray indicates a small pulmonary laceration. A followup xray or two may be needed to ensure that it does not expand or cause a pneumothorax. Thoracic surgery involvement is not usually indicated
  • Hemoptysis is normal, and may present immediately or several days later. The patient should be reassured in advance so they don’t call you frantically in the middle of the night.

Image source: internet

    Hare Traction – Putting It On, Taking It Off

    Femoral traction devices have been around for a long time. One reader has asked about the timing of removal of these devices after they arrive at the hospital. I learned a number of things while reviewing the literature to answer this question.

    Most importantly, there is really only one indication for applying a traction splint to the femur: an isolated, relatively mid-shaft femur fracture. Unfortunately, there are lots of contraindications. They consist of other injuries or fractures that could sustain further damage from traction. Specifically, these include:

    • Pelvic or hip fracture
    • Hip dislocation
    • Knee injury
    • Tib/fib, ankle or foot fracture

    I did find one interesting study from 1999 that looked at how useful these splints really were. Of 4,513 EMS runs, only 16 had mid-thigh trauma and 5 of these appeared to have a femur fracture. Splint application was attempted in 3, and only 2 were successful. This was the experience in only one city (Evanston, IL) for one year. However, it mirrors what I see coming into our trauma center.

    Unfortunately, when it comes to removal, there are very few guidelines out there. My advice is to have your orthopedic surgeon evaluate as soon as imaging is complete. They can help decide whether converting to some type of definitive traction is necessary, or whether it can be changed to a more conventional splint. In any case, the objective is to minimize the total amount of time in the traction splint to avoid any further injury to other structures.

    Reference: Prehospital midthigh rauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 19:137-140, 2001.

      Managing Chest Tube Air Leaks

      There are a lot of opinions and not so much literature on how to manage chest tube air leaks. Here is some practical advice on how to deal with this occasional problem.

      Most air leaks are an alveolar-pleural fistula, representing a connection between a very small airspace and the pleura. This should not be confused with a bronchopleural fistula, which involves larger airways and is much more challenging to manage.

      First, identify what kind of leak it is. Remember, dry seal chest tube systems will not show an air leak unless it has a fluid chamber that can be filled with water (see related post below).

      • Expiratory – occurs during normal expiration only
      • Forced expiratory – occurs only with coughing
      • Inspiratory – occurs during inspiration in ventilated patients
      • Continuous

      Inspiratory leaks are rare and should be managed conservatively with maneuvers to minimize airway pressures. Continuous air leaks can be monitored, but may indicate a bronchopleural fistula.

      Expiratory and forced expiratory types account for about 98% of all air leaks. Small air leaks should be managed with water seal, not with increased suction. The main concept is to reduce air flow through the fistula so it can heal. A prospective study has shown that this technique stops small to moderate size leaks sooner than leaving on suction.

      Larger air leaks will probably not seal on their own and are probably not safe to place on water seal. They will likely require pleurodesis, either chemical or mechanical via a VATS procedure. Blood and fibrin patches have also been tried.

      Any air leak that extends hospital stay should be evaluated for appropriateness of discharge with a Heimlich valve or VATS pleurodesis.

      References:

      • A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thoracic Surg 66:1726-1731, 1998.
      • Prospective randomized trial compares suction versus water seal for air leaks. Ann Thoracic Surg 71:1613-1617, 2001.

      Related posts:

      Field Concussion Testing For Athletes

      Public awareness of concussions, particular those from sports, is on the rise. It’s difficult enough for trauma professionals to diagnose some of the milder forms of head injury. Expecting lay people to do this is just not realistic.

      Most people have heard of ImPACT testing for head injury. This involves determining a player’s baseline ability to remember a series of words. It tests memory, attention span and reaction time. A baseline study is required, and the test takes about 20 minutes to administer using a computer.

      The King-Devick test is a numerical processing tool that can be administered using an iPad or a deck of cards. A baseline value is required as well, and the test takes about 2 minutes to administer. See the video for details.

      Both tests have been validated by a number of scientific studies, and both are only available for purchase. Several hospitals, trauma centers, and schools have purchased the programs and will administer them for free. 

      Check out these valuable programs and consider providing them at your own local sporting events.

      Links:

      Related post: TBI screening with the Short Blessed Test