All posts by TheTraumaPro

What To Do When The Chest Tube Is Not In The Right Place

It happens from time to time. Your patient has a hemothorax or pneumothorax and you insert a chest tube. Well done! But then the xray comes back:

The last hole in the drain is outside the chest! What to do???

Here are the questions that need to be answered:

  • Pull it out, leave it, or push it in?
  • Does length of time the tube has been in make a difference?
  • Does BMI matter?

Leave comments below regarding what you do. Hints and final answers next!

When Should You Activate Your Backup Trauma Surgeon?

The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

  • It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
  • It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail. 

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.

The 30-Minute Rules: Documentation

In my last post, I reviewed timing for the 30-minute rules. When does the 30-minute timer actually start? When does it stop? Now that you understand those concepts, we can move on to actually documenting those times.

As I noted yesterday, the timer starts when the consultant is called or paged. It should be easy to record this, right? Nope. The problem is that a whole host of people can do this:

  • ED clerk
  • Trauma nurse
  • Attending surgeon
  • Resident
  • Medical student (nooooo)
  • And probably more

This makes it more difficult to find a common place to record the call time. The two possibilities are paper or electronic. The paper trauma flow sheet is usually only available to the trauma nurse. The others will either use a random piece of paper that gets lost, or doesn’t record it at all.

The other option is the electronic medical record (EMR). Everyone involved with the resuscitation probably has access to it. What’s the best option? This depends on your hospital. For paper, develop a process such that one person who has access to the trauma flow sheet (usually the nurse) is responsible for entering the call time. Otherwise, develop a specific template in your EMR so that whoever enters it does it the same way. And make sure that everyone who could possibly write the call time note knows how to properly create it.

Now, what about documenting consultant arrival? This is the most difficult part of the process. Once again, there are two alternatives: human factors or technology. Many programs try to rely on technology. Unfortunately, it is frequently flawed. The EMR timestamp when the consult is entered always  occurs after the patient was seen. Badge swipes can be forgotten. The most reliable method relies on personal responsibility. Your consultant must take a moment to check the time when he or she enters the room to examine the patient. They can then record that time when they write their note. And if they really want to be cool, they can also note the time they were called in the note.

Best practice: Have the trauma attending personally make the call to the specialist. And in that conversation, have them mention that “this is a 30–minute criterion consult.” This ensures that both your surgeon and consultant know that their presence is expected promptly. And maintain an expectation that the consultant will properly document their arrival time.

I hope you enjoyed this series. If you have any comments or questions, or want to share tips from your program, please leave a comment below or shout it out on Twitter.

The 30-Minute Rules: Response Times

In my last post, I reviewed the first component of the 30-minute rules, the actual criteria themselves. It’s not called a 30-minute response rule for no reason. There is an absolutely required time to respond that has been set at 30 minutes.  Today, I’ll look at an equally important component: the response time itself. Why do we have it, and when does the event start and stop?

So why does a rule like this exist? Is it to punish the providers who are being monitored, torturing them to get to the hospital as quickly as possible? No! As with so many of our performance improvement (PI) filters, they are designed to test many, many things. Some examples for this one are:

  • Recognition of a life or limb threatening condition by the in-hospital providers
  • Communications systems (ED clerk, pagers, phones, etc.)
  • The call schedule system
  • Clinician responsiveness and commitment (orthopedics, neurosurgery)
  • Nursing documentation
  • And more!

What is the actual time interval that must be measured? First, it does not start when the clinical condition in the criterion is recognized. If a patient has a large subdural hematoma with shift on CT scan, a radiologist must bring it to the attention of the advanced practice provider, emergency physician, or surgeon, who must then take the next step. The timer actually starts when the clinician causes the specialist to be notified. This may occur when the clerk pages or calls them, or when the clinicians do it directly.

One point of confusion: the clock does not start when the clinician responds to the page or call. What if they don’t call back for 45 minutes? Do they then have another 30 minutes to get to the hospital? No!! It starts when the first notification goes out.

So when does the clock stop? This one is easy. It occurs when the specialist who has been called gets to the patient’s bedside and begins the assessment.

One final thing about the clock? Does the clinician have to respond within the 30-minute time frame on every patient? Ideally, this would be great but it’s not realistic. There is no guidance in the Orange Book about a threshold. But if past experience is any indication, it is most likely a timely response somewhere around 80% of the time. But strive for perfection!

Tomorrow, I’ll list some ways to address the most challenging part of the 30-minute rules: actually recording the response times. And I’ll provide a best practice to help meet it.

 

The 30-Minute Rules: What Are They Exactly?

Yesterday, I talked about the new 30-minute rules for orthopedics and neurosurgery in general terms. Today, I’ll write about the who and what.

The rules state that a service representative “must be present and respond within 30 minutes based on institutional-specific criteria.” The response needs to be in person and not by phone. But who can it be? The Clarification Document states that the response can be met by an orthopedic surgery resident, mid-level provider, or the orthopedic surgeonHowever, if a resident or midlevel respond, they must document their communication with the orthopedic surgeon in their note.

The neurosurgery service representative is not as clearly spelled out. However, it is presumed that this person meets the same requirements as for orthopedics: resident, midlevel, or neurosurgeon.

The most important issue the trauma program must address is the selection of the actual criteria.  Here are some tips to guide you:

  • Select only a few. Three is a good number. Any more than this will tax your specialists.
  • Choose good criteria that your orthopedic surgeon or neurosurgeon would absolutely want to be there  in 30 minutes for. See my examples below.
  • Make sure they are very specific. Vague terms like “TBI” or “open fracture” would result in your specialist being called in way too often.
  • Ensure that the criteria do not rely on the judgement of the specialist. For example, language such as “a subdural requiring operative intervention” requires the neurosurgeon to pass judgment from home and should be avoided.
  • One exception to the previous point: futile neurotrauma care. Your neurosurgeon may review the images from outside the trauma bay and pronounce the care futile. Howeverthey should document this clearly in a note in the chart as soon as possible. And they had better not change their mind later.
  • Avoid vague language like “when requested by the trauma team.”

So what are some good criteria? Here are a few:

  • Ortho
    • Mangled extremity
    • Dysvascular limb
    • Compartment syndrome
    • Unstable pelvic fracture
    • Open pelvic fracture with external hemorrhage
  • Neurosurgery (you/they pick the exact numbers)
    • Subdural/epidural > x mm
    • Subdural/epidural with midline shift > x mm
    • Subdural/epidural with impending herniation
    • Open skull fracture with brain extrusion
    • Brain extrusion from nose/ear
    • Decrease in GCS of > x points
    • Unilateral dilated pupil with GCS < x points
    • Spinal cord injury with unstable spine

This is not a comprehensive, list, but hopefully you get the idea. Each center needs to develop their own list, with input from their specialists. Once agreed upon, these should be put into policy and approved at the trauma program operations committee.

Tomorrow: call and response.