All posts by TheTraumaPro

Next Trauma MedEd Newsletter – Trauma in Pregnancy

Injuries to pregnant women causes a lot of anxiety among trauma professionals. Not only is there one obvious seriously injured patient, but there’s a baby involved that is relatively invisible using the tools available in the trauma resuscitation room.

To help demystify and de-anxiefy (just made it up), the next newsletter will cover trauma in pregnancy in detail. Topics will include:

  • Tips and tricks
  • Predicting outcome
  • Monitoring
  • Safe imaging
  • Perimortem C-section
  • And more!

If you haven’t already, subscribe to my Trauma MedEd newsletter so you can get this edition as soon as it’s released. Otherwise, it will be released here on the blog about 2 weeks later.

Click here to subscribe and download back issues!

The Seventh Law of Trauma

Your patient is at their healthiest as they roll in through the emergency department door

Yes, major trauma patients are sick, but they are going to get sicker over the next few hours to days. No matter how bad they look now, they will tolerate more at the time you first see them than they will tomorrow.

Too often, we look at them and delay because “they are too sick to operate.” This is usually not the case.

Bottom line: Move quickly, get surgical clearances done promptly, and perform all interventions (especially major surgery) early before your trauma patient gets really sick!

Other Laws of Trauma:

Cognitive Bias – Don’t You Hate It When They Do That?

cognitive_bias

Source: http://chainsawsuit.com/comic/2014/09/16/on-research/

I sat in on a committee meeting once where the management of a particular clinical problem was being vigorously discussed. One of the participants pulled out his smartphone, did a quick search, and said, “Aha! This article shows that my opinion is correct!”

This approach is wrong on so many levels, it’s almost laughable. But it illustrates a real weakness that all human beings have: susceptibility to cognitive bias. 

Scientists have identified somewhere between 150 and 200 different types of cognitive bias, and trying to sort them out will literally make your head spin. For a quick and enlightening read, I recommend reading the article below. It sifts through the mess and lumps them into four understandable categories.

Bottom line: We are all capable of warping what we read, hear, and see to fit our own vortex of pre-existing beliefs. It’s very important to recognize the possibility of bias when you are seeking information so that you can do everything to minimize its impact. If you can’t or won’t do that, then you’ll end up being that know-it-all guy with the smartphone.

Related post:

Trauma Morning Report – A Best Practice?

Hospital medicine in general, and inpatient trauma care specifically, is now characterized by a series of handoffs. These occur between physicians, trainees, nurses, and a host of other trauma professionals. Many trauma centers have implemented a “morning report” type of handoff, which formalizes part of the process and frequently adds a teaching component.

The group at the University of Arkansas studied the impact of implementing a morning report process on length of stay and care planning. Prior to the study, residents handed off care post-call to other residents without attending surgeon involvement. The morning report process added the presence of the post-call surgeon, and the trauma and emergency general surgery attendings coming on duty. Advanced practice nurses collected information on care plan changes.

Here are the factoids:

  • Problem: There is mention of a survey with 79% response rate detailing 219 trauma admissions during the 90 day study period. This is not explained anywhere else in the abstract, so it is not clear if the data presented represents all admissions.
  • 69% of patients were admitted to a ward bed, and 31% to ICU
  • Change to the care plan occurred during morning report in 20% of patients
  • The most common care plan changes were: addition of a procedure in 45%, medication change in 34% (typically pain management)
  • Mean hospital length of stay decreased from 10 to 6 days (!)

Bottom line: This small, prospective study quantifies a few of the benefits of a formal “morning report” process. The fact that just a little bit of trauma attending oversight decreased length of stay by a whopping 4 days suggests that the residents really needed the increased supervision. Discharge planning is a multidisciplinary activity, and should be a major part of the rounding routine as well.

Formalizing the handoff process is always a good thing. Yes, it takes time and planning, but as this and other studies have shown, it is well worth the effort!

Related posts:

Reference: Morning report decreases length of stay in trauma patients by changing care plans in 20% of patients. AAST 2016, Poster 124.

ED Use of CT – Everyone Does It Differently

There is tremendous variability in ordering imaging in trauma patients. To some degree, this is due to the dearth of standards pertaining to radiographic imaging, at least in trauma. And when standards do exist, trauma professionals are not very good at adhering to them. We’d rather do it our way. Or the way we were trained to do it.

The group at Jamaica Hospital in Queens, NY quantified some of those differences, studying ordering patterns of trauma surgeons (TS), emergency physicians (EP), and surgery chief residents (CR). Unfortunately, they then tried to draw some interesting conclusions, which I’ll discuss at the end.

They reviewed all blunt trauma activations over a 6 month period at their urban trauma center. At the end of each trauma activation, each of the three physician groups wrote imaging orders, but only the trauma surgeons’ were submitted. Missed injuries were defined as any that would not have been found based on each provider group’s orders. Extremity injuries, and those found on physical exam or plain imaging were excluded.

Here are the factoids:

  • The authors do not state how many patients they saw in this period, but by extrapolation it appears to be about 250
  • Trauma surgeons ordered significantly more studies (1,012) than the EPs (882) or CRs (884)
  • This resulted in essentially a “pan-scan” in 78%, 64%, and 69%, respectively
  • Radiation exposure was said to be the same for all groups (18 vs 13 vs 15 mSv) [I’m having a hard time buying this]
  • But cost was higher in the trauma surgeon group ($344 vs $267 vs $292) [Huh? Is this only the electric bill for the CT scanner? Very low, IMHO]
  • And the trauma surgeons had a missed injury rate of only 1%, vs 11% for EPs and 7% for CRs [Wow!]

Bottom line: Sorry, I just can’t believe these results. There are a lot of things left unsaid in this poster. What were all these missed injuries? What magical CT scan that only the trauma surgeons ordered actually picked them up? And probably most importantly, were they clinically significant? A small hematoma somewhere doesn’t make a difference (see the “tree falls in a forest” post below).

It looks to me like the authors wanted to justify their use of pan-scan, and push their emergency physicians to follow suit. Unfortunately, this is a poster presentation, meaning that there will be limited opportunity to question the authors about the specifics.

The debate regarding pan-scan vs selective imaging is an active one. The evidence is definitely not in yet. While we sort it out, the best path is to develop a reasonable imaging practice guideline based on the literature, where available. Some areas such as head and cervical spine CT have been worked out fairly well. Then fill in the blanks and encourage all trauma professionals in your hospital to follow them. There is great value in adhering to good guidelines, even when there are blanks in our knowledge.

Related posts:

Reference: Variability in computed tomography imaging of trauma patients among emergency department physicians and trauma surgeons with respect to missed injuries, radiation exposure and cost. AAST 2016, Poster #75.