All posts by The Trauma Pro

The Value Of Reinterpreting Outside CT Scans

February 21, 2022 The Trauma Pro Leave a comment

Okay, one of your referring hospitals has just transferred a patient to you. They diligently filled out the transfer checklist and made sure to either push the images to your PACS system or include a CD containing the imaging that they performed. For good measure, they also included a copy of the radiology report for those images.

Now what do you do?

Read the report and consider the results
Look at the images yourself and make decisions
Have your friendly neighborhood radiologist re-read the images and produce a new report

Correct answer: all of the above. But why? First, you can get a quick idea of what another professional thought about the images, which may help you think about the decisions you need to make.

And one of the few dogmas that I preach is: “read the images yourself!” You have the benefit of knowing the clinical details of your patient, which the outside radiologist did not. This may allow you to see things that they didn’t because they don’t have the same clinical suspicion. Besides, read the images often enough and you will get fairly good at it!

But why trouble your own radiologist to take a look? Isn’t it a waste of their time? Boston Children’s Hospital examined this practice in the context of taking care of pediatric trauma patients. This hospital accepts children from six hospitals in the New England states. In 2010, they made a policy change that mandated all outside images be reinterpreted once the patient arrived. They were interested in determining how often there were new or changed diagnoses, and what the clinical impact was to the patient. They focused their attention only on CT scans of the abdomen and pelvis performed at the referring hospital.

Here are the factoids:

168 patients were identified over a 2-year period. 70 were excluded because there was no report from the outside hospital (!), and 2 did not include the pelvis.
Reinterpretation in 28% of studies differed from the original report (!!)
Newly identified injuries were noted in 12 patients, and included 7 solid organ injuries, 3 fractures, an adrenal hematoma, and a bowel injury. Three solid organ injuries had been undergraded.
Four patients with images interpreted as showing injury were re-read as normal
Twenty of the changed interpretations would have changed management

Bottom line: Reinterpretation of images obtained at the outside hospital is essential. Although this study was couched as pediatric research, the average age was 12 with an upper limit of 17. Many were teens with adult physiology and anatomy. There will be logistical hurdles that must be addressed in order to get buy-in from your radiologists, such as how they can get paid. But the critical additional clinical information obtained may change therapy in a significant number of cases.

Reference: The value of official reinterpretation of trauma computed tomography scans from referring hospitals. J Ped Surg 51:486-489, 2016.

Philosophy

Stroke And Fall VS Fall And Bleed

February 17, 2022 The Trauma Pro Leave a comment

It’s like the old chicken and egg question. When dealing with head trauma and falls, which came first? Did the patient have a stroke and then fall down? Or did they fall and sustain some type of intracranial hemorrhage? And you may ask, does it make a difference? They are going to get a head scan anyway, right?

In my opinion, it makes a big difference! How often have you seen the following scenario? EMS is called to a house or nursing home for someone who has fallen. They notice some extremity weakness on one side and presume the patient is having a stroke. The emergency department is then notified that a stroke patient is inbound.

On arrival, the patient was rapidly assessed and whisked off to CT scan for a CT and angiogram, possibly with neurology present. My experience is that a majority of these scans is negative for CVA. And many are positive for some type of extra-axial hemorrhage like subdural or epidural blood from the real injury.

Unfortunately, something called anchoring bias is likely to occur in this situation. Everyone from the paramedics onward are moving along under the assumption that the patient has had a stroke. They stop considering the more common diagnosis of TBI and other potential injuries in the spine and torso. Even when the CT angiogram is found to be negative, it’s difficult for people to change gears. It then takes longer to address the subdural or epidural. The involved trauma professionals are less likely to activate the trauma team. And further evaluation of the chest, abdomen, and spine may be delayed or forgotten for a time.

Bottom line: In any case of a fall followed by neurological changes that could indicate stroke, always presume a serious TBI first! If EMS requests a stroke code, it should be changed to a trauma activation prior to patient arrival. This takes advantage of the odds (more in favor of TBI) and activates a team that is well versed in evaluating the entire patient. If no evidence of hemorrhagic stroke is present, the team will then order the brain CTA and involve the stroke team as necessary.

And for good measure, every one of these cases that does start as a stroke evaluation should be addressed by the trauma performance improvement process!

Trauma Center

The Value Of In-House Call – Part 2

February 8, 2022 The Trauma Pro Leave a comment

In my last post, I detailed an older study that did not show much of an impact from having the trauma surgeon in-house at all times. However, like many of the papers published on this over the years, it suffered from small numbers and questionable endpoints.

A group in the Netherlands sought to analyze everything they could find on the topic and perform a meta-analysis and systematic review. They scanned the literature beginning in 1976, the year that the ACS Committee on Trauma published the first resource criteria for trauma center verification. A total of 16 studies (RCTs and observational) that included information on over 64,000 patients were carefully selected for study. The endpoints of interest were in-hospital mortality and several process measures including lengths of stay and time to OR and CT.

Here are the factoids:

In-house mortality significantly decreased with in-house surgeons, with a relative risk reduction of 14% (from good quality papers, primarily published after 2000)
ICU length of stay was shorter with an in-house surgeon in four studies, longer in one
Hospital length of stay was shorter with the in-house surgeon in four studies, longer in two
Time to OR was significantly faster in seven studies with an in-house surgeon, but no difference was seen in five
Time to CT was shorter in one study and no different in four with the in-house surgeon

Bottom line: What does it all mean? We have been led to believe that doing a meta-analysis / systematic review can help us make sense of a group of papers with flaws such as low numbers, questionable design, or bias. This work shows that this is not necessarily the case.

Think of a good meta-analysis as a set of eyeglasses focused on a selected body of literature. The blurry individual papers are grouped together and brought into better focus by the meta-analysis process. However, the final visual acuity is still determined by the overall quality of the individual research works.

If the overall quality is low, things will remain somewhat blurry even after meta-analysis. As individual paper quality improves, or the papers at least include some higher quality data mixed in with chaff, the overall clarity of the meta-analysis gets better and better.

In this meta-analysis, all papers included mortality information. There is enough there to show the association of an in-house trauma surgeon and lower mortality. But as with all association studies, it is impossible to say that the improved survival is due to the surgeon alone. There are many other factors that were not or could not be evaluated in the studies that might parallel the presence of the surgeon. And similarly with the process measures (LOS, time to resource use), we are generally seeing a preponderance of that show a positive effect. But it’s still not open and shut.

I interpret this meta-analysis / systematic review as overall positive and supportive of having an in-house surgeon. It definitely dovetails with my own experience with in-house call over the past 38 years. I recognize the crudeness of the outcome measures selected, and our inability to quantify more subtle benefits. And we still haven’t fully figured it out the value, even after over 20 years of decent studies. This means we probably won’t ever fully know the answer since the system we work in continues to shift, potentially rendering the older information obsolete.

We will most likely continue with in-house call at highest-level trauma centers for the foreseeable future. In my opinion, and as is suggested by most of the literature, that is a good thing for our patients.

Reference: In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis, Journal of Trauma and Acute Care Surgery: August 2021 – Volume 91 – Issue 2 – p 435-444,

Trauma Center

The Value Of In-House Call – Revisited Again

February 2, 2022 The Trauma Pro Leave a comment

The value of in-house call for trauma surgeons has been contested for over a decade. Metrics for attending surgeon presence for trauma activations first appeared in the 2006 Optimal Resource document from the American College of Surgeons (Green Book). It called for the surgeon to ideally be present upon patient arrival, and no later than 15 minutes afterwards. This necessitated many trauma centers to mandate that the surgeons take in-house call so they could meet this standard.

As you might imagine, many were not happy about this. At Level I centers, the surgeons wanted to be able to rely on residents to help meet this requirement. The ACS was not too keen on letting them. So of course, people started doing research on the topic to prove their point of view.

I’m going to start off with an early paper on the topic from 2013. It was a rather sad initial attempt to show that surgeon presence didn’t make a difference. I’ll re-review that paper today, then move on to a more interesting one in my next post.

Of note: if you read just the abstract of this paper, you may come to the wrong conclusion! This is a perfect example of why you can’t just rely on the title or the abstract. Sometimes they cover up major flaws in the study.

This retrospective study primarily of changes in patient mortality, as well as a few other length of stay (LOS) indicators as the center changed over from having trauma surgeons who took call from home to taking in-house call. It involves only one trauma center in Lexington, Kentucky and covers two 21 month periods.

Here are the factoids:

There were roughly 5000 patients each in the at-home and in-house groups
Overall demographics looked identical, even though the authors thought they detected differences in age and ISS
Time in ED, ICU LOS, hospital LOS decreased significantly, and percent taken to OR increased in the in-house group. There was no change in mortality.
These patterns were the same in trauma activation patients, who were obviously more seriously injured.
The authors conclude that having an in-house surgeon does not impact survival, but can speed things up for patients throughout their hospital stay.

I have many problems with this study:

The statistical results are weird. Many of the allegedly significant differences appear to be identical (e.g. mean age 44+/-19 vs 45+/-19, hospital LOS 3 days vs 3 days). And even if the authors found a test that makes them look statistically significant, they are clinically insignificant. ICU LOS differences were measured in hours, and 25 hours was significant?
Attending presence “improved” from 51% to 88%. This means that they were not present in 1 of 5 trauma activations. This can easily overshadow any positive effect their presence may have had.
Mortality is too crude an indicator to judge the value of surgeon presence.
Lengths of stay can be due to so many other factors, it is not a valid measure either.
A retrospective, registry study has too few of the really critical data points

Bottom line: This paper is the poster child for why you MUST read the full paper, not just the abstract. If you had done the latter, you may believe that having an in-house surgeon is not necessary. Many papers prior to 2013 (of variable quality) have looked at this (poorly) and there is no consensus yet. But in-house call is a requirement for ACS verification if the surgeon can’t make it to the bedside of a seriously injured patients within 15 minutes.

After observing trauma activations for 40 years, I know there is value in having an experienced surgeon present at the bedside during them. However, this value is very hard to quantify and every paper that has tried thus far has not looked at the right variables. And these variables cannot be assessed in a retrospective, registry type study.

In my next post, I’ll look at a recent and better paper on the topic.

Reference: Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency. J Am College Surg 281(4):734-738, 2013.

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