All posts by TheTraumaPro

What Is The Curbside Consult?

Surgeons, I’m sure you’ve had an experience something like this at some point:

You happen to be wandering through the emergency department and one of your Emergency Medicine colleagues approaches you and says, “Hey, I ‘ve got this patient I’m seeing that I just want to run by you…”

How should you deal with this? They want a quick tidbit of information to help them decide what to do with the patient. Can they send them home, or should they “formally” consult you?

It’s important to look at the pros and cons of this practice. First the pros:

  • It’s direct. You’re right there. No phone calls, no paging.
  • It’s quick. Just a quick description  of the problem, and a prompt answer. Then everyone can get on with their business.

But then there are the cons:

  • Situational accuracy. The consultee has not seen the patient, so the information they have been given was filtered through the consulter. Any number of cognitive biases are possible, so the real story may not be exactly as it seems.
  • Interpretation of the recommendation. Other cognitive biases are also possible as the consulter acts on and implements the recommendations of the consulter. Have they really been followed?
  • Lack of documentation. This is the biggest problem with a curbside consult. The consultee may act without documenting the source of the recommendation. Or, they may document that they spoke with Dr. Consultee. In either case, one or the other may be hung out to dry, so to speak.

Consider what happens if there is a complication in the care of that patient. There is no way to really determine what was said during that conversation a week or two years later. It boils down to recollections and may end up as a he said … she said situation. And in the worst case scenario, if such a case were to enter the medicolegal arena, there is no official record that any recommendation was made or followed. It’s a very easy case for the plaintiff’s attorney to prevail.

Those of you who have been following me for some time may be familiar with my Laws of Trauma. Originally, there were ten.

But the curbside consult leads to my new Eleventh Law of Trauma:

Work not documented is work not done

Bottom line: There is no such thing as a curbside consult! The consultee should say, “I’d better take a look at this patient, why don’t you officially consult me?”

In doing this, the consulter gets to use their own clinical and cognitive skills, and thus render a real opinion based on first hand experience. The consultee gets the most accurate recommendations possible, and they are noted in the record so there is no room for misinterpretation. And finally, there is good documentation from both that will stand up in a court of law if needed.

The Second Head CT In Patients Taking DOACs

Direct oral anticoagulant drugs (DOACs) are here to stay. When they were first released, I was very concerned with our inability to reverse them. I feared that we would have a rash of our elders presenting with severe head bleeds that we could do nothing about.

Well, that has not materialized. In fact, it appears that the probability of serious bleeding is more likely with our old reversible workhorse drug, warfarin.

But we are still spooked by DOACs. Nearly every center that has a practice guideline for managing patients with TBI on blood thinners includes a repeat CT scan after a given time interval. This is typically 6, 12, or even 24 hours.

Given the evolving safety profile of DOACs, is this even necessary? The surgical group at the Henry Ford Wyandotte Hospital in Michigan performed a retrospective registry review for their Level III trauma center. They reviewed the data for all adult patients who had suspected or confirmed blunt head trauma (any mechanism), were taking a DOAC, and received at least one CT scan.

Here are the factoids:

  • There were 400 patients with 498 encounters (yes, 15% came back with another TBI)
  • Patients were elderly (mean age 76) and nearly evenly split by sex
  • Fall was the most common mechanism (97%)
  • The first scan was negative in 96% of patients;12% of them did not have a repeat scan
  • Of the 420 patients who had a second scan, 418 were negative (99.5%). The two with positive scans were discharged uneventfully.
  • There were no differences based on specific DOAC, presenting GCS or mechanism

Bottom line: This is a relatively small, single institution study. However, it does appear that the authors have a large population of elderly patients suffering falls. This paper suggests that, indeed, a second scan may not be necessary. This parallels data from my own hospital. But to be on the safe side, keep an eye out for bigger, multi-institutional studies to be sure.

Reference: The utility of a second head CT scan af-ter a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs). Injury, article in press, June 13, 2021.

Are You A TXA Believer, Or TXA Hesitant?

I’ve visited several hundred trauma centers over the past 25 years, and recently I’ve begun to appreciate that there are two camps when it comes to the use of tranexamic acid: the TXA believers and the TXA hesitant.

There have been a number of large studies that seem to suggest a benefit with respect to survival from major hemorrhage, particularly if given soon after injury (CRASH-2, MATTERs). This drug is dirt cheap and has been around a long time, so it has a clearly defined risk profile.

However, many of those hesitant to use it point to the possibility of thromboembolic events that have been sporadically reported. Several years ago, I did my own literature review and found that the number of thrombotic events from TXA was nearly identical to that of transfusing plasma.

JAMA Surgery just published a large systematic review, meta-analysis, and meta-regression that sought to examine the association between thromboembolic events (TE) in patients of any age and involving all medical disciplines, not just trauma.

The anesthesia group at the University Hospital Frankfurt in Germany did a systematic search of the Cochrane Central Register of Controlled Trials, as well as MEDLINE, for randomized controlled trials involving TXA. They covered all published studies through December 2020.

The authors adhered to standard guidelines for con-ducting reviews and meta-analysis (PRISMA). They specifically searched for outcomes involving TEs, such as venous thromboembolism, myocardial infarction or ischemia, limb ischemia, mesenteric thrombosis, and hepatic artery thrombosis. They also tallied the overall mortality, bleeding mortality, and non-bleeding mortality.

Here are the factoids:

• A total of 216 eligible trials were identified that included over 125,000 patients

• Total TEs in the TXA group were 1,020 (2.1%) vs 900 (2.0%) in the control group

• Studies at lowest risk for selection bias showed similar results

Bottom line: The authors concluded that IV TXA, irrespective of the dose, does not increase the risk of thromboembolic events. Period.

Hopefully, this is the final study needed to convince the TXA hesitant that it is safe to administer. They may still argue the efficacy, but at less than $100 per vial it is becoming impossible to ignore.

Reference: Association of Intravenous Tranexamic Acid
With Thromboembolic Events and Mortality A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surgery 156(6):3210884, 2021.

The September Issue of the TraumaMedEd Newsletter is Live!

The September issue of the Trauma MedEd newsletter is now available to everyone!

In this issue, get some tips on:

  • Managing Penetrating Injury
  • Nursing Tips For Pediatric Orthopedic Injury
  • Abdominal Packing Tips
  • Geriatric Trauma Management
  • Tips For Trauma In Pregnancy
  • Managing CSF Leaks

To download the current issue, just click here!

Or copy this link into your browser:
https://www.traumameded.com/courses/practical-tips/

This newsletter was released to subscribers a few weeks ago. If you would like to be the first to get your hands on future newsletters, just click here to subscribe!

Animals vs Cars: What To Do

This is a bad time of year in much of the United States for striking animals on the road. In my part of the country, the deer are out in full force. Car vs animal can be challenging, and motorcycle vs animal is frequently deadly. What can our patients do to protect themselves?

  • Be especially vigilant when driving for the first few hours after sunset and just before sunrise. More animal activity occurs during these hours.
  • If one animal is spotted, look out for others.
  • Drive with high beams on as much as possible. In many animals, this will show reflections from their eyes. Some large animals, such as moose, don’t have glowing eyes.
  • Always where a seat belt in case an impact does occur.
  • If an animal is spotted, slow down quickly and blow the horn.

Most important! NEVER swerve or attempt to quickly change direction. This is one of the most common errors that results in serious injury or death. The driver swerves to avoid the animal and begins to leave the roadway. They then over-correct in the opposite direction, triggering a rollover. Always make gentle corrections, staying in the same lane.

For small animals, slowly adjust the steering wheel to straddle them with the wheels. For larger ones, try to plan the impact so it is in front of the unoccupied front passenger seat. If the seat is occupied, plan the strike in the middle of the hood. The idea is to keep the car occupants safe, but to assist with natural selection and remove the animal from the gene pool.