All posts by The Trauma Pro

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Shift Work And Fatigue In Air Medical Crews

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Most trauma professionals are shift workers to one degree or another. It is well documented that sleep problems and fatigue can occur with this type of work, depending on the structure of the shift. A number of studies have been carried out in physicians and prehospital providers. But what about prehospital air crews?

Air medical providers are faced with two challenges: critically ill and injured patients and a challenging work environment. Typically, work consists of 12 or 24 hour shifts, and all of this is conducive to sleep problems and fatigue. 

The University of Pittsburgh looked at this problem, performing a battery of questionnaires and cognitive tests in their air medical service before and after each shift. They studied 37 subjects, and found the following interesting tidbits:

  • 95% of all crew members had poor baseline sleep quality
  • Fatigue levels decreased over the shift (both 12 and 24 hr)!
  • Crews were able to get some sleep while on duty (1 hour in a 12 hour shift, 7 hours in a 24 hour shift)
  • There was a mild increase in cognitive test performance at the end of the shift, although it was not statistically significant

Bottom line: Don’t anyone try to generalize these results to all flight crews! This was a sample of a single flight service, and is not necessarily representative of others. Poor baseline sleep quality is likely due to the fact that many flight nurses and paramedics hold other jobs. In this particular case, the decreasing fatigue may simply be due to the fact that they are encouraged to get some rest while on duty and actually do it. Make sure that your agency has fatigue reducing and fatigue avoidance policies and procedures. It’s for your safety as well as your patient’s!

Related posts:

Reference: The effect of shift length on fatigue and cognitive performance in air medical providers. Prehosp Emerg Care (early online, 2013)

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How To Remove An Impaling Object

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The books all say “transport the patient with an impaling object in place” and “only take the impaling object out in the operating room.” Is this realistic? How do you actually take that knife out?

First, you need to decide if the patient belongs in the OR right now. Are they hemodynamically unstable? Is there obvious arterial bleeding? If so, don’t dawdle. Proceed to the operating room and surgically expose the problem completely.

If the patient is safe to stay in the ED, do what you need to figure out the exact anatomy of the wound (and object). This may involve imaging, usually CT scan. Once the exact position of the object is understood, build an anatomical picture of the situation in your mind. What named arteries might be involved? What other vital structures? 

Given this anatomic information, a decision can then be made regarding the best location for removal. The majority of the time, this will be in the operating room. It is best to obtain optimum surgical exposure prior to pulling it out. In the abdomen, this is easy. However, some areas (skull, sinuses) are tricky and may not require exposure of the end of the tract. Visualization of the remaining hole(s) is key so that bothersome bleeding can be recognized immediately.

The object should be grasped firmly and carefully and removed in one smooth motion. Visual monitoring for five minutes will virtually eliminate the presence of bleeding. If it does occur, then deeper exploration is warranted. In the awake patient, I generally push gently on either side of the entry point prior to and during the pull to provide some sensory distraction. Then I hold pressure on the site for 5 minutes (no peeking) to assure myself that there is no bleeding.

And don’t forget the forensics! Let the police photograph the patient. Handle the object carefully so as not to disturb any fingerprints. Place it carefully in a paper bag, labelled appropriately. And always make sure that a chain of evidence form is properly filled out so it and the object itself can be handed over to the proper authorities.

General

Where Do You Resuscitate Your Trauma Patients?

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Sounds like an easy question, right? In the trauma resuscitation room! But how long can (should) they stay there? Can they leave for testing and come back? As you may expect, there are a lot of variables to consider.

All major trauma patients should start in the resuscitation room. In a few institutions around the world this may be an OR, but this is uncommon. I’m talking about major injuries, multiple fractures, significant potential for blood loss, not the minor stuff. Once the necessary stabilization and evaluation is complete, the patient may need further diagnostics like CT or plain xrays. But once those are done, where does the patient with ongoing resuscitation needs go?

In many cases, they end up back in the ED. Some surgical specialists may want to evaluate them there. They may need minor procedures like suturing or traction pin placement. An ICU bed might not be immediately available. But is this really the right place?

Unfortunately, it isn’t. This class of patient needs ICU care, which includes very close monitoring and ongoing attention to resuscitation. This level of care is just not available in a busy emergency ward. The physicians are seeing other patients, and the nurses may be less familiar with continuously providing this level of care. Arterial line and ICP placement / monitoring is difficult. It’s really not the right place to be.

Bottom line: There are only two places for a complex patient with ongoing resuscitation needs: a surgical ICU or an operating room. The choice depends on whether the patient really needs an operation now. If not, they should be resuscitated in an ICU prior to general anesthesia. The trauma physician must triage all requests for tests or minor procedures from consultants, keeping the overall patient condition in mind. If a particular test will not significantly alter near-term management, it must be postponed. If an ICU bed is not available, the ED resuscitation room may be the only alternative. In this case, a nurse (preferably with ICU experience) must stay with the patient at all times. And an experienced trauma physician should ideally be there as well, if not in person, at least by phone (and quickly). Finally, get the patient to an ICU as soon as humanly possible!

General

Trauma Center Level And Outcome

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All designating/verifying agencies differentiate between highest level trauma centers (regional resource, or Level I in the US) and an intermediate level center (Level II in the US). For most, the differences are not huge on paper. Level I’s usually require a significant education and research component, as well as continuously available specialists in all disciplines. There are usually minimum volume and/or injury severity requirements as well.

Several previously published reports using NTDB data have shown that mortality is decreased in trauma patients taken to Level I centers compared to Level II. A report out this month confirms this using data from the Pennsylvania Trauma System Foundation database. The authors noted the following:

  • Patients admitted to Level I centers were younger and more often male than those admitted to Level II
  • Level I’s admitted more patients with gunshots and fewer with same level falls
  • Overall, mortality of patients admitted to Level I centers was 15% lower than in those admitted to a Level II
  • This survival advantage was principally in the most severely injured patients (20% in patients with ISS >= 25). In lower ISS patients, there was no apparent survival advantage.
  • Complication rates were 37% higher in Level I centers!

Bottom line: What does all this actually mean? First, this applies in the US only. Next, this study shows an association, but can’t assign a cause for the better survival. But it is consistent now across a number of studies. The US criteria for Level I centers are fairly stringent. Level II criteria are less so. Some Level II’s function like a Level I, but others are barely better than a Level III. It’s time to figure out what those less tangible differences are and implement them as best practices for all centers, if possible. And, oh yes, we better figure out why the major complication rate in Level I’s is so ridiculously high. It does no good to survive if the patient sustains significant functional limitations due to complications!

Reference: Impact of Trauma Center Designation on Outcomes: Is There a Difference Between Level I and Level II Trauma Centers? Journal Amer Coll Surgeons 215(3):372-378, 2012.

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Best Of: How To Read A Stab Wound

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Most emergency departments do not see much penetrating trauma. But it is helpful to be able to learn as much as possible from the appearance of these piercing injuries when you do see them. This post will describe the basics of reading stab wounds.

Important: This information will allow some basic interpretation of wounds. It will not qualify you as a forensics expert by any means. I do not recommend that you document any of this information in the medical record unless you have specific forensic training. You should only write things like “a wound was noted in the midepigastrium that is 2 cm in length.” Your note can and will be used in a court of law, and if you are wrong there can be significant consequences for the plaintiff or the defendant. This information is for your edification only.

1. What is the length of the wound? This does not necessarily correspond to the width of the blade. Skin stretches as it is cut, so the wound will usually retract to a length that is shorter than the full width of the blade.

2. Is the item sharp on one side or both? This can usually be determined by the appearance of the wound. A linear wound with two sharp ends is generally a two sided knife. A wound with one flat end and one sharp end is usually from a one-sided weapon. The picture below shows a knife wound with one sharp side.

Single edge knife wound

3. Is there a hilt mark? This can usually be detected by looking for bruising around the wound. The picture below shows a knife wound with a hilt mark.

Knife wound with hilt mark

4. What is the angle? If both edges are symmetric, the knife went straight in. If one surface has a tangential appearance, then the knife was angled toward that side. You can approximate the direction of entry by looking at the tangential surface of the wound edge. In this example, the blade is angling upward toward the right.

Angled knife entry

5. How deep did it go? You have no way of knowing unless you have the blood stained blade in your possession. And yes, it is possible for the wound to go deeper than the length of the knife, since the abdominal wall or other soft tissues can be pushed inwards during the stab.