All posts by TheTraumaPro

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.

The Value of Protocols in Trauma

Earlier this week, I wrote about several protocols that can be used in patients with rib fractures. Most trauma centers have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question arose: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

Financial Triage (Wallet Biopsy) and Transfer to Trauma Centers

A significant amount of volume coming in to Level I and Level II trauma centers is transferred from other hospitals. Occasionally, concerns are raised that some hospitals “cherry pick” the patients, retaining those who are insured and transferring those who are not. If this is true, it has the potential to undermine the entire trauma transfer system by delaying and impeding patient care and by financially damaging the higher level trauma centers. A few single state or single health care system studies have been performed, and some of them have suggested that the uninsured were more likely to be transferred to high level trauma centers.

The group at Parkland looked at a national sample using the National Trauma Databank, and compared the insurance status of patients transferred to Level I and II centers to those retained at Level III and IV centers. Overall, most patients (83%) were insured. At first glance, transferred patients were significantly more likely to be uninsured (18% vs 14%). However, they were also more seriously injured and more likely to have multiple injuries. When adjusted for these differences, the transferred patients were no more likely to be uninsured than the others.

Bottom line: There does not appear to be any concerted effort nationally to inappropriately transfer uninsured injured patients to high level trauma centers. The perception arises because the uninsured have a tendency toward higher risk behaviors that may result in serious injury.

However, it is possible that cherry picking may occur on occasion at the local level. If you are a trauma director experiencing this phenomenon, the best course of action is to speak directly to the director at the referring hospital. Politely discuss your perceptions and offer to see if there is anything you can do to help with their triage process. Frequently, letting them know you are aware of the pattern causes them to improve their transfer decision making.

Reference: Financial triage in transfer of trauma patients: a myth or a reality. Am J Surg 198(3):e35-e38, 2009.

Brain Injury and Chemical Prophylaxis for DVT

Deep venous thrombosis (DVT) and its complications are recognized and common problems in trauma patients, particularly those with traumatic brain injury (TBI). We know that giving chemical prophylaxis like heparin and low molecular weight heparin (LMWH) reduces the risk. Unfortunately, trauma professionals (and neurosurgeons in particular) are reluctant to give it after acute TBI for fear of making intracranial hemorrhage worse.

Froedtert Hospital in Milwaukee modified their protocol for TBI patients to allow chemical prophylaxis to start 24 to 48 hours after a 24 hour followup CT that showed no progression of any bleeding. Therefore, prophylaxis could be started 48 to 72 hours after injury. They used subq heparin three times daily, or LMWH twice daily. All others received mechanical prophylaxis and were screened twice weekly by duplex ultrasound. The chemical prophylaxis group was not screened routinely. 

A total of 812 patients were studied, half of whom received early prophylaxis per protocol. The average Abbreviated Injury Score for the head in these patients was 3.4, which represents fairly serious injury. There was a significant decrease in the incidence of DVT in the chemical prophylaxis group (1% vs 3%). More intriguing, there was a lower rate of injury progression in this group as well (3% vs 6%), although not quite statistically significant.

Bottom line: Although this is a small and retrospective study, it was well designed and relatively large compared to most other similar work. It shows that use of chemical prophylaxis works in patients with serious TBI, and appears to be safe. Similar protocols should be considered by trauma program multidisciplinary operations committees to further systematize this process. 

Reference: Safety and efficacy of prophylactic anticoagulation in patients with traumatic brain injury. J Am Coll Surg 213:148-154, 2011.

Related post: Does interrupting DVT prophylaxis increase risk for it?

Chest Tube Tips

I’ve written a lot about chest tubes, but there’s actually a lot to know. And a fair amount of misinformation as well. Here’s some info you need to be familiar with:

  • Chest trauma generally means there is some blood in the chest. This has some bearing on which size chest tube you choose. Never assume that there is only pneumothorax based on the chest xray. Clot will plug up small tubes.
  • Chest tubes for trauma only come in two sizes: big (36Fr) and bigger (40Fr). Only these large sizes have a chance in evacuating most of the clot from the pleural space. The only time you should consider a smaller tube, or a pigtail type catheter, is if you know for a fact that there is no blood in the chest. The only way to tell this is with chest CT, which you should not be getting for diagnosis of ordinary chest trauma.
  • When inserting the tube, you have no control of the location the tube goes once you release the instrument used to place it. Some people believe they can direct a tube anteriorly, posteriorly, or anywhere they want. They can’t, and it’s not important (see next tip).
  • Specific tube placement is not important, as long as it goes in the pleural space. Some believe that posterior placement is best for hemothorax, and anterior placement for pneumothorax. It doesn’t really matter because the laws of physics make sure that everything gets sucked out of the chest regardless of position except for things too big to fit in the tube (e.g. the lung).
  • Tunneling the tube tract over a rib is not necessary in most people. In general, we have enough fat on our chest to ensure that the tract will close up immediately when the tube is pulled. A nicely placed dressing is your insurance policy.
  • Adhere to an organized tube management protocol to reduce complications and the time the tube is in the chest.

And finally, amaze your friends! The French system used to size chest tubes is the diameter of the tube in millimeters times three. So a 40Fr chest tube has a diameter of 13.3mm.

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