I’m on my way to Dubai to visit the Arab Health Expo 2014 at the Convention Center. I’d like to encourage any of my readers from the Middle East to stop by and say hi! I’ll be in the United States expo area at the Minnesota International Medicine booth. Please stop by to chat! I’ll be there from Tuesday through Thursday, then will head home.
See you there!
When one works in the trauma field, or medicine in general, we deal with the need for sterility all the time. We use equipment and devices that are sterile, and we administer drugs and fluids that are sterile. In surgery, we create sterile fields in which to use this sterile stuff.
In the past few years, we’ve come to the realization that the sterility we take for granted may not always be the case. There have been several cases of contaminated implanted hardware. And most recently, supposedly sterile injectable steroids were found to be contaminated with fungus, leading to several fatal cases of meningitis.
A recent article in the New England Journal of Medicine brings a bizarre problem to light: microbial stowaways in the topical products we use to sterilize things. Most drugs and infused fluids are prepared under sterile conditions. However, due to the antimicrobial activity of topical antiseptics, there is no requirement in the US that they be prepared in this way.
A number of cases of contamination have been reported over the years:
- Iodophor – contamination with Burkholderia and Pseudomonas occurred during manufacture, leading to dialysis catheter infection and peritonitis
- Chlorhexidine – contaminated with Serratia, Burkholderia and Ralstonia by end users, leading to wound infections, catheter infections, and death
- Benzalkonium chloride – contaminated with Burkholderia and Mycobacteria by end users, causing septic arthritis and injection site infections
Bottom line: Nothing is sacred! This problem is scarier than you think, because our most basic assumptions about these products makes it nearly impossible for us to consider them when tracking down infection sources. Furthermore, they are so uncommon that they frequently may go undetected. The one telltale sign is the presence of infection from weird bacteria. If you encounter these bugs, consider this uncommon cause. Regulatory agencies need to get on this and mandate better manufacturing practices for topical antiseptics.
Reference: Microbial stowaways in topical antiseptic products. NEJM 367:2170-2173, Dec 6 2012.
A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:
Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.
In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.
Here are some tips for each of the areas:
- Penis – Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
- Scrotum – Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
- Vagina – external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
- Perineum – Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
- Anus – Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
- Natal cleft – Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position.
Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.
The majority of trauma patients are seen initially at non-trauma centers. And the majority of those patients can be treated just fine at that local hospital. However, a few (some say about 15%) do need to be transferred. The question frequently arises, “what studies do I need to do before transferring?”
The danger is that doing things that slow down the transfer can result in bad outcomes. For example, a patient may have a spleen injury that is actively bleeding. Every minute that this patient is not receiving “definitive treatment”, she loses more blood. And every cc of blood lost causes her to inch closer to shock, other complications, or death.
The key is to get people who need a higher level of trauma care on their way to a higher level trauma center as soon as the need is recognized. There is a natural tendency to do diagnostic studies, such as CT scan, in these patients. Sometimes they are needed to actually figure out what is going on. But more often they are obtained to “do a complete workup” or because “the trauma center expects me to.”
Unfortunately, these are incorrect assumptions. The complete workup cannot be used by the referral center if they are shipping the patient, and for a variety of reasons they may not be useful to the trauma center. This is one of the major reasons that referral patients receive extra radiation exposure. About half of the studies performed at the referral hospitals need to be repeated!
The Referral Hospital Trauma Rule: Do any simple study needed to ensure the patient will stay alive until the helicopter/ambulance arrives (typically chest or pelvic xray). If at any point, you see something obviously not treatable at your hospital (i.e. open fracture, GCS 8, partial amputation), DO NO FURTHER STUDIES AND PREPARE TO TRANSFER. If the patient does not have such an obvious problem, do only the tests you need to determine if you can keep the patient. But as soon as you find anything that you cannot treat, stop further studies and prepare to send the patient onward. And don’t forget to send working copies of the few studies that you did get.
If you’ve been reading these posts for any length of time, you may have realized that I regularly write about new (or sometimes not so new) research studies that I believe have some impact on trauma professionals. But if you look closely, you’ll see that the vast majority are human studies. I can only recall 1 or 2 animal studies that I’ve commented on in the past 3+ years.
Why is that? Well, there are several reasons.
First, many of those papers describe low-level biomedical research that is tough for the average person to follow. They use sophisticated measurement and analysis techniques to pick apart a specific biological pathway or process. It almost takes a PhD to understand them.
Next, most of these studies are performing work that only incrementally increases our understanding of what’s going on at that microscopic level. These little bits of progress may ultimately add up to a major advance. But if I find it difficult to provide the big picture view of the importance of one of these minor findings to the average trauma professional, I’m not going to write about it.
Finally, and most importantly, many of these published results will not have any significance to our field. Some interesting, positive finding in an animal model may have been discovered. But why should we believe this will translate to something relevant to humans?
Look at the model of inflammation that’s been used to develop all manner of potential human drugs to block it in critically ill patients. To date, there have been nearly 150 such drugs developed and tested, at great expense. How many have actually worked and been approved for human use? Zero. Why? It turns out that the inflammation model used in mice creates a response that looks the same as what happens to humans. But it’s not. It turns out that completely different, parallel pathways have been studied. So the thousands of papers that picked apart these pathways used to treat mouse inflammation do not really apply to human medicine. Only to veterinary medicine. And mice veterinarians only!
Reference: Genomic responses in mouse models poorly mimic human inflammatory diseases. Proc Nat Acad Sciences, ePub Feb 11, 2013.