All posts by TheTraumaPro

Best Of: VIP Syndrome In Healthcare (Very Important Person)

The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.

Who is a VIP? It may be a celebrity. A family member. Or even a colleague. VIPs (or their healthcare providers) may have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.

Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.

Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.

How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to allproviders who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.

Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.

Trauma In Pregnancy 7: C-Section – Technique (with video)

Your preparation. You should already have full personal protective gear on, right? Right? Your existing gear is just fine. You do not need to change to sterile gown and gloves. The time wasted is probably not worth the low risk of infection in the rare event that the mother survives.

You need at least one assistant, preferably two. They will pass you instruments and provide retraction. Continue CPR throughout the procedure.

At the same time, call your OB and neonatal colleagues, if you haven’t already. If you don’t have any at your hospital, don’t sweat it. If you do, don’t wait for them to arrive.

Patient preparation. Have someone quickly insert a foley catheter.

Do not use sterile technique. It just slows things down. The bladder needs to be empty so you can quickly and easily get to the uterus.

The procedure. Here’s the blow by blow:

  • Splash some betadine on the skin. The mother is probably not going to survive, so infection is not a concern.
  • Make a midline, vertical incision from mid-epigastrium to pubis. Extend down to the midline fascia.
  • Enter the peritoneal cavity near the umbilicus. Extend the incision along the full length of the skin incision using scissors.
  • Use the scalpel to make a 4cm vertical incision near the top of the uterus. Insert your 2nd and 3rd fingers into the uterus, directed downwards. Use them to protect the fetus from the scissors as you use them to extend the uterine incision downwards.
  • Rupture the membrane with a clamp and deliver the baby. Remember, the membrane is tough! Insert your hand deep into the lower uterus under the baby’s head. Flex the body as you gently push upwards to deliver the head first. Suction the mouth and nose, then deliver the shoulders and body.
  • Cut and clamp the cord. Hand off the baby to another team for suctioning and resuscitation.
  • Continue to try to revive the mother. If circulation is restored, move immediately to an OR for delivery of the placenta, control of the bleeding that was killing her in the first place, and hopefully, closure.

Here’s a video that shows how quickly the procedure can be done (with a few edits). Just watch the first 47 seconds!

Trauma In Pregnancy 6: C-Section – Tools

Most emergency departments do not have a separate perimortem C-section pack sitting on the shelf. And when you finally need it, that is not the time to make one up. Most emergency departments have some type of major cutdown or mini-laparotomy tray available. Here is the absolute minimum required. Make sure these are on your existing tray.

  • Large scalpel – note that this should be a disposable type that is opened and dropped onto the tray
  • 3 large retractors for the helpers
  • Toothed forceps
  • Metzenbaum scissors
  • Heavy scissors
  • Multiple large clamps and hemostats

Yup, that’s all the heavy equipment you really need!

Trauma In Pregnancy 5: C-Section – When?

The perimortem C-section (PMCS) is a heroic procedure designed to salvage a viable fetus from a moribund mother. Interestingly, in some mothers, delivery of the fetus results in return of spontaneous circulation.

The traditional teaching is that PMCS should be started within 4-5 minutes of the mother’s circulatory arrest. The longer it is delayed, the (much) lower the likelihood that the fetus will survive.

The reality is that it takes several minutes to prepare for this procedure because it is done so infrequently in most trauma centers. Recent literature suggests the following management for pregnant patients in blunt traumatic arrest (BTA):

  • Cover the usual BTA bases, including securing the airway, obtaining access and rapidly infusing crystalloid, decompressing both sides of the chest, and assessing for an unstable pelvis
  • Assess for fetal viability. The fundus must measure at least 23 cm.
  • Assess for a shockable vs non-shockable rhythm. If shockable, do two cycles of CPR before beginning the PMCS. If non-shockable, move straight to this procedure.

Bottom line: Any time you receive a pregnant patient in blunt arrest, have someone open the C-section pack while you assess and try to improve the mother’s viability. As soon as you complete the three tasks above, start the procedure! You don’t need to wait 4 minutes!

Trauma In Pregnancy 4: Imaging

Everyone worries about imaging pregnant patients. As with most medical tests, it always boils down to risks vs benefits. What are the chances of causing mutations or cancers or a spontaneous abortion, and what is the risk of missing a critical injury? In general, reasonable studies involving a fetus at just about any point in gestation won’t cause major problems. At least as far as we know. What is not clear are the longer term, hard to measure effects. So the general philosophy should be to order just what you absolutely need, and shield the fetus during any studies other than of the abdomen/pelvis.

Now, to put these numbers into perspective, have a look at this list of delivered doses from common studies. The table above is listed in milliGrays, and this one is in milliSieverts. These are roughly comparable, except that the former is a measure of radiation dose absorbed, and the latter measures radiation delivered.

Bottom line: Think hard about the imaging you really need. If you generally do this for all patients, you probably won’t change your practice in pregnant women. Don’t worry about chest and pelvic x-rays. Shield the fetus for anything not involving the abdomen/pelvis. For major torso trauma, you probably will need CT of the chest/abdomen/pelvis. If so, do it right. Order with contrast so you don’t get substandard images that need to be repeated.