All posts by TheTraumaPro

Are Graduating General Surgery Residents Qualified To Take Trauma Call?

Trauma training during general surgery residency has changed dramatically over the past two decades. Although we like to blame the 80-hour work week rule on everything, there are other factors that may be at play. Increasing use of nonoperative management, availability and increasing scope of interventional radiologists, and the increasing number of surgical subspecialists are certainly significant.

The surgical group at LAC+USC looked at changes in operative caseloads, type of surgery performed, and the impact that concurrent subspecialty training has had on trauma operative volumes. The authors reviewed 16 years of ACGME data on resident surgical procedures in various body regions by year of training. They specifically looked at the impact of implementation of the 80-hour work week.

Here are the factoids:

  • There was a trend only (p=0.07) toward decreased operative trauma cases
  • The number of trauma laparotomies increased, vascular procedures decreased, and neck explorations and thoracotomies remained stable
  • Trauma vascular procedures decreased for surgical residents, but increased for vascular fellows
  • Individual resident operative volumes in chest, abdomen, solid organ, and extremities decreased after implementation of the 80-hour work week
  • Based on this, the authors recommend residents who are interested in a career in trauma and acute care surgery have fellowship training (??)

Bottom line: Well, it was a catchy title, at least. Or is it a promotion for trauma fellowships? The differences between pre-80 hour and post-80 hour in the table are not that impressive, and although a number of the operative case comparisons reach statistical significance, they represent a difference of only 1 case! Not clinically relevant! And other than the number of laparotomies going up, the other numbers looked fairly constant. 

The exposure to operative cases overall appeared to remain constant for most procedures with the exception of laparotomies increasing and vascular cases decreasing. In my opinion, one of the most apparent changes is in resident comfort with critical decision making. I don’t believe that this is due to any change in operative experience, but rather to closer oversight by attending surgeons and less opportunity to independently come to those decisions.

Reference: Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. J Trauma 82(3):470-480.

When Did The Surgeon Arrive At The Trauma Activation?

All trauma centers have mandatory arrival requirements for the surgeon at their highest-level trauma activations. Most Level I and II centers abide by the American College of Surgeons (ACS) requirement of 15 minutes after patient arrival. Level III centers typically mandate 30 minutes for their highest-level activation. And failure to meet these criteria can actually lead to loss of verification.

But what is the best way to record this critical piece of information? A number of methods have been used over the years. The earliest was simply recording the time of surgeon arrival on the paper trauma flow sheet. This has evolved over the years as technology has advanced. Most hospitals have installed badge swipe systems, since name badges have become nearly ubiquitous for gaining access to restricted areas within the hospital. A paper published last year details one hospital’s experience using a badge swipe system to do just this.

A NYC metro area Level I center started using a name badge swipe system to record the surgeon’s arrival in the ED for trauma activations several years ago. They examined their trauma activation data over a 7 month period at the end of 2016. Surgeon arrival times were recorded on the trauma flow sheet, and the electronic swipe information was included to supplement flow sheet results.

Here are the factoids:

  • There were 531 trauma activations during the study period, with 50 highest-level activations and 481 limited activations
  • The overall paper trauma flow sheet completion rate was 50% without card swipe data (!!)
  • For highest-level activations, surgeon presence was documented in 76%, but they arrived on time (< 15 minutes) only 70% of the time (!!!)
  • For intermediate-level activations, surgeon arrival was recorded 47% of the time and the surgeon was on time 45% of the time (I’m running out of exclamation points!!)
  • After including the badge swipe data, overall completion rate “improved” to 70%, which broke down to 90% in highest-level and 68% in the intermediate level activations
  • Surgeon compliance with arrival times improved to 84% and 63% for the two activation levels

The authors blamed the poor record keeping and compliance on “the fast pace of an ED.” They concluded that the badge swipe system was successful in increasing documentation and arrival compliance.

Bottom line: Oh, this is a fail on so many levels! First, surgeon arrival timeliness was appalling both with and without the badge swipe data. It started at 50% and increased to a barely passing score of 84%. And since this center only receives 100 highest-level activations per year, just a few more slip-ups could easily result in their loss of Level I verification. The increase in arrival compliance after adding badge data could be due to better documentation or better response because the surgeon knew they were being watched (Hawthorne effect).

Obviously, there are many reasons for documentation problems. The surgeon may have, indeed, been late. The scribe may not have been paying attention, or forgot to write the time in because things were busy. The flow sheet could be poorly designed, or worse, electronic.

The addition of technology to overcome human limitations is not the panacea many think it is. First, it’s expensive, especially if new gadgets are being purchased. In this case, it’s the same card swipe technology that is already present in the hospital. So there’s no additional cost in this case.

But it is always more work for some of the humans involved. Card swipe systems do not automatically integrate with a trauma flow sheet, even an electronic one. So some poor human will be tasked with getting the badge swipe report from security. Then, they will have to pore over the myriad card swipes and match the activation times to the data seen on the report. This can be time consuming in a busy ED.

I am still a big believer in personal responsibility. The key players, namely the surgeons, need to feel responsible for reporting their arrival time as a statistic vital to verification of their center. Only when they actually do, and this becomes part of the culture of the entire trauma team, will documentation and compliance approach perfection!

Reference: Implementation of a Radio-frequency Identification System to Improve the Documentation and Compliance of Attending Physicians’ Arrival to Trauma Activations. Cureus 10(11):e3582, 2018.

Trauma Activation vs Stroke Code

Let’s look at an uncommon scenario that crops up from time to time. Most seasoned trauma professionals have seen this one a time or two:

An elderly male is driving on a sunny afternoon, and crashes his car into a highway divider at  25 miles per hour. EMS responds and notes that he has a few facial lacerations, is awake but confused. They note some possible facial asymmetry  and perhaps a bit of upper extremity weakness. No medical history is available. Witnesses state that he was driving erratically before he crashed. Medics call the receiving trauma center in advance to advise them that they have a stroke code.

Is this a reasonable request? Stroke centers pride themselves on the speed of their stroke teams in assessing, scanning, and when appropriate, administering thrombolytics to resolve the problem. But if there are suspicions of stroke in a trauma patient, which diagnosis wins? Trauma team or stroke team?

Lets analyze this a bit further, starting with diagnosis. Remember the first law of trauma:

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Could the symptoms that the paramedics are observing be due to the car crash? Absolutely! The patient could have a subdural or epidural hematoma that is compressing a cranial nerve. There might be a central cord injury causing the arm weakness. His TBI might be the source of his confusion. The facial asymmetry could be due to a pre-existing Bell’s palsy, or he could have had a stroke years ago from which he has only partially recovered.

If the stroke team is called for the patient, they will focus on the neuro exam and the brain. They will not think about trauma. They will follow the patient to CT scan looking for the thing that they do best with. If they don’t see it, the patient will return to the ED for (hopefully) a full trauma workup. If there are occult injuries in the abdomen, then the patient may have been bleeding for an hour by then. This elderly patient will then be way behind the eight ball.

And let me pose the worst case scenario. The patient is taken to CT by the stroke team, and lo and behold he has a thrombotic stroke!  This patient had a stroke, which caused him to lose control of his car and explains most of his findings. Again, the stroke team will do what they are trained to do and give a thrombolytic. They are still not thinking about trauma. Within minutes the patient becomes hypotensive and his abdomen appears a bit more distended. He is rushed back to the ED (remember, no CT in hypotensive patients even if you are in the scanner) and a FAST exam is very positive for free fluid throughout the abdomen. Imagine the look you will get from the surgeon as they run to the OR to perform a splenectomy on this fully anticoagulated patient!

Bottom line: If you have a patient who is trauma vs stroke, trauma always wins! Remember the first law and try to find traumatic reasons for all signs and symptoms. Perform your standard trauma workup and incorporate the appropriate head scans into your evaluation. Then and only then should the stroke team be called.

Solid Organ Injury Practice Guideline Updated

Regions Hospital developed a clinical practice guideline for solid organ management in 2002-2003. It has been revised a few times over the years, as any good guideline should with the availability of new data.

I’ve just put the finishing touches on the latest revision as a result of the updated organ scaling rules published by the American Association for the Surgery of Trauma. I reviewed the new scales for both liver and spleen earlier this year (links below). In the previous iteration of the scaling system, the importance of contrast pooling (pseudoaneurysm) or extravasation beyond the organ was not well defined. 

The new guideline explicitly includes these injuries in the high grade group, which for us is grade IV or V. Technically, pseudoaneurysm of the liver is only grade III, but in my opinion demands angiographic investigation and embolism. Thus the inclusion in the high grade / angiography arm of our guideline.

For those of you who have not seen this guideline before, there are several important directives that are listed on the left side of the page:

  • Patients are NOT made NPO
  • They do NOT have activity restrictions (such as bed rest)
  • Serial hemoglins are NOT drawn
  • An abdominal CT scan is NOT repeated

These changes were made in 2015 based on our clinical experience that properly selected patients almost never failAnd they still don’t, so why starve, restrain, poke, and re-irradiate them?

Additionally, we included explicit impact activity restrictions for post-discharge so that patients would get the same message from all members of our team.

Click the image below to download the guideline and have a look. I’m interested in your comments!

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Tension Pneumothorax From Inside The Chest: The Video

This video shows what it looks like from the inside when a needle thoracostomy is inserted into the chest. Note that it takes about a minute for the lung to expand, so be patient when you insert the needle. You can also get an idea of why the needle is only a temporary measure as the inflating lung begins to kink the catheter.

Don’t ask why there was a thoracoscope in the chest with a tension pneumo in the first place, though!