All posts by TheTraumaPro

Surgeons Who Operate Post-Call

Fatigue is a big deal for trauma professionals. I previously devoted a week of posts to detailing research on fatigue, and dedicated the June 2012 Trauma MedEd newsletter to the topic. So I just reviewed a paper suggesting that it might not be such a big deal for attending (consultant) surgeons who operate after they’ve been on call.

The whole idea came about because residents in the US (registrars) have had restrictions to their work hours in place for 10 years, limiting them to only 80 hours per week. Yet the attending physicians, who are older and more likely to show the effects of fatigue, have no such limits. They can work as long as they want. Maybe their greater experience or long-established habits of occasional sleep deprivation are protective?

The group in Memphis looked at this phenomenon, performing a retrospective review of patients operated on by surgeons post-call and those who were not. They looked at 737 patients over 3.5 years, of which 15% were performed by post-call staff surgeons. Here are the key points:

  • Only cholecystectomy, hernia and intestinal procedures for bowel obstruction, ischemia or bleeding were evaluated
  • The authors used complications and readmission as outcomes to monitor
  • Complications occurred in about 13% of both post-call and no-call groups. No difference.
  • Readmissions within 30 days occurred in about % of both groups. Again, no difference.

So it looks like it’s okay to operate after the surgeon’s been up at night, right? Wrong! This is another perfect example of why it’s so important to read the whole paper, not just the abstract. Major problems:

  • The actual amount of sleep or fatigue levels are not quantified, so it’s a mix.
  • It’s a teaching hospital, so the surgeons always operate with a trainee at some level. The residents either do the work, or can “double check” the surgeon’s work to prevent any significant errors.
  • Complications and readmission rates are very crude indicators of error. Only the most egregious problems would manifest as one of these.

Bottom line: There is plenty of non-medical literature out there that shows that fatigue is bad (aviation, trucking, marine operations). And as much as we’d like to believe it, surgeons and other physicians are in no way immune to its effects. What this paper really showed is that if you are supervising a well-rested trainee and looking at outcomes that aren’t directly related to fatigue, everything looks great! It’s not, and all trauma professionals need to be aware of the fact that, even though they feel invincible and that they can do anything after sleep deprivation, it’s just their fatigue talking. Protect your patients and make sure that everyone who takes care of them is in tip-top shape.

Reference: Outcomes of operations performed by attending physicians after overnight trauma shifts. Journal Am Coll Surg, in press 11 Jan 2013.

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CIWA Demystified

What exactly is the CIWA protocol?

It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.

The Clinical Institute Withdrawal Assessment measures 10 items that are association withdrawal:

  • Nausea / vomiting
  • Anxiety
  • Paroxysmal sweats
  • Tactile disturbances (itching, bugs crawling on skin, etc)
  • Visual disturbances
  • Tremors
  • Agitation
  • Orientation
  • Auditory disturbances
  • Headache

All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.

The total score is used to determine whether benzodiazepines should given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.

The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.

For a copy of the CIWA scoring criteria, click here.

Acute Ethanol Intoxication And The Banana Bag

It’s one of those time honored treatments that most hospital-based providers are familiar with. The banana bag, reserved for intoxicated patients presenting to the ED or admitted to the hospital. They’ve been around so long, we just take them for granted. But like most things that have become dogmatic, they are due to be questioned from time to time.

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A banana bag is a proprietary mix of “good” stuff, including electrolytes and vitamins, especially thiamine and magnesium. The exact content varies from hospital to hospital. Thiamine and other B vitamins give the resulting solution the characteristic color, hence the term “banana.”

Does it actually do good things like ward off Wernicke’s encephalopathy and megaloblastic anemia? A paper from Jacobi Medical Center in the Bronx prospectively evaluated a series of intoxicated people entering their ED. They drew vitamin B12, folate, and thiamine levels to see if they were deficient enough to even need vitamin supplementation.

Interesting findings:

  • These folks (only 77 patients) were very drunk! Average BAC was 280mg/dL.
  • Vitamin B12 and folate levels were not critically low in any patient
  • Thiamine was low in 15% of patients, but none had clinical evidence of a deficiency
  • Later review of prior visits revealed that some patients with low levels had received a previous banana bag within 1 month. Did it do any good?

Bottom line: Most of our intoxicated patients are not vitamin deficient, and don’t need supplementation. The real kicker is that  we almost never really try to find out if the patient might be a chronic abuser and potentially at risk. We just hang the bag. Remember, everything we do in medicine has a potential downside. And if the patient really doesn’t need a banana bag in the first place, there is no benefit to balance that risk. The next time you ask for that little yellow bag, think again!

Reference: Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med 26(7):729-795, 2008.

EMS Spine Precautions And Use Of The Long Backboard

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma have just released a position statement clarifying the use of spine precautions and backboards in trauma patients. Backboards have been used since forever in preparing to move injured patients to hospitals. Unfortunately there are several problems:

  • The benefits of backboard use has never really been shown
  • Backboards can cause more injury, including pain, agitation, and skin breakdown
  • The risks vs benefits of using a backboard are seldom considered

So the following recommendations have been made:

  • Appropriate patients for backboard use include those with blunt trauma and altered consciousness, spine pain / tenderness / deformity, neurologic deficit
  • Additional patients who might benefit include those with a high energy mechanism and intoxication, inability to communicate, or distracting injury. Note that these leave a lot to the imagination!
  • Patients with penetrating injury to head, neck or torso without neurologic deficit do not need a backboard
  • Rigid cervical collar alone is sufficient in most patients who are ambulatory at the scene, will undergo a long transport time, or for whom a backboard is not otherwise indicated (see next bullet)
  • Backboard is not necessary in patients who meet all the following criteria: GCS 15, no spine tenderness or abnormality, no neurologic deficits, no distracting injury and not intoxicated
  • Even if a backboard is not necessary, EMS personnel should always be aware of other spine precautions, including a collar, securing the stretcher, minimizing patient movement, and maintaining inline stabilization when needed
  • The backboard should be removed as soon as practical in the ED

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Reference: EMS spinal precautions and the use of the long backboard. Prehosp Emerg Care ePub March 4, 2013.

Jehovah’s Witnesses And Blood Transfusion Demystified

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encounted in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses beleive that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

  • Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
  • Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
  • Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availabilty of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
  • Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
  • Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
  • Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
  • Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.