All posts by TheTraumaPro

July Trauma MedEd Newsletter Topic: Field Amputation

This is probably one of the worst calls a trauma surgeon can get: “Please dispatch a surgeon to the scene. We need a field amputation to extricate the patient.”

For trauma professionals in any discipline, this is probably a once in a career event. And for that reason, there is likely to be a lot of confusion.

The next newsletter will cover this topic in detail. Topics include:

  • Statistics on how often field amputation is needed
  • Indications for the procedure
  • Logistics: getting to the scene and staying safe
  • Essential equipment
  • Sample policies
  • And more!

If you haven’t already, subscribe to my Trauma MedEd newsletter so you can get this edition when it’s released on September 1. Otherwise, it will be released here later in the month.

Click here to subscribe and download back issues!

New Technology: The AED Drone

The media tends to give drones a bad name. And certainly, there are careless operators out there who may give drone operators a bad name. But it seems that everyone is getting in the game. Amazon wants to use drones to deliver your orders. Police use them to find missing people, and criminals. Parks use them to protect animals and property.

But how about some medical uses? Sure, they can be used to access austere environments, and potentially to deliver medical supplies. But here is an example of a very creative use. It’s an AED drone!

This drone was designed from the ground up to provide emergency assistance for cardiac arrest. It’s got audio, video, and is a flying defibrillator. Watch this 3 minute video to see how it works and how it was made.

Timed PI Audit Filters: When Does The Clock Start?

This is a question that comes up frequently in trauma performance improvement programs. Several of the performance improvement (PI) audit filters typically used at trauma centers include a time parameter. Some of these include:

  • Craniotomy > 4 hrs
  • Laparotomy > 4 hrs
  • OR for open fracture > 8 hrs (although this is now outdated)
  • OR for compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

There are several possible points at which to start the clock:

  • Time of the scene of the traumatic event
  • Recognition at an outside hospital (for referred patients)
  • Arrival in your  ED
  • When the diagnosis is made in your ED
  • When the decision to operate occurs

The answer is certainly open to interpretation. 

Here is my opinion on it:

The purpose of a PI filter is to measure system performance. There are a myriad of system problems that can delay taking a patient to the OR. These include care delays in the ED, delays in getting or interpreting diagnostic tests, delays in contact or response for consultants, delays in diagnosis, delays in OR scheduling or availability, and more. Does it make sense to limit the evaluation of your system by setting one of the later decision points as your start time?

Bottom line: I recommend starting the audit filter clock at the time of patient arrival in your ED. This enables the PI program to evaluate every system in your hospital that can possibly enable or impede your patient’s progress to the OR. However, if the issue was recognized at an outside hospital, scrutiny of their processes also needs to occur. Their trauma PI coordinator needs to know so they can make sure the transfer to definitive care occurred as quickly as possible. 

You’ve Been Pimped! Again!

What exactly is pimping? If you have ever been a medical student or resident in any discipline, you probably already know. It’s ostensibly a form of Socratic teaching in which an attending physician poses a (more or less) poignant question to one or more learners. The learners are then queried (often in order of their status on the seniority “totem pole”) until someone finally gets the answer. But typically, it doesn’t stop there. Frequently, the questioning progresses to the point that only the attending knows the answer.

So how did this time honored tradition in medical education come about? The first reference in the literature attributes it to none other than William Harvey, who first described the circulatory system in detail. He was disappointed with his students’ apparent lack of interest in learning about his area of expertise. He was quoted as saying “they know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped!”

Other famous physicians participated in this as well. Robert Koch, the founder of modern bacteriology, actually recorded a series of “pümpfrage” or “pimp questions” that he used on rounds. And in 1916, a visitor at Johns Hopkins noted that he “rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

So it’s been around a long time. And yes, it has some problems. It promotes hierarchy, because the attending almost always starts questions at the bottom of the food chain. So the trainees come to know their standing in the eyes of the attending. And they also can appreciate where their fund of (useful?) knowledge compares to their “peers.” It demands quick thinking, and can certainly create stress. And a survey published last year showed that 50% of respondents were publicly embarrassed during their clinical rotations. What portion of this might have been due to pimping was not clear.

Does pimping work? Only a few small studies have been done. Most medical students have been involved with and embarrassed by it. But they also responded that they appreciated it as a way to learn. A 2011 study compared pimping (Socratic) methods to slide presentations in radiology education. Interestingly, 93% preferred pimping, stating that they felt their knowledge base improved more when they were actively questioned, regardless of whether they knew the answer.

So here are a few guidelines that will help make this technique a positive experience for all:

For the “pimpers”:

  • Make sure that the difficulty level of questions is reasonable. You are testing your learners’ knowledge, not spotlighting your own mental encyclopedia
  • Build the level of difficulty from questions that most can answer to one or two that no one knows, then switch to didactice teaching of the esoterica
  • Don’t let one learner dominate the answers; gently exclude them and solicit answers from others so they get a chance to participate
  • Provide positive reinforcement for correct answers, but don’t resort to negative reinforcement (insults) when they are wrong
  • Go Socratic when the answer is not known. Step back and review the basic concepts involved that helps your learners arrive at the correct answer.

For the “pimpees”:

  • Read, read, read! You are in this to learn, so study all the clinical material around you.
  • Talk to your seniors to find out your attending’s areas of interest. There’s a lot of stuff to learn, and this may help you focus your rounding preparation a bit. It still doesn’t absolve you from learning about all the other stuff, though.
  • Don’t be “that guy (or gal)” who tries to dominate and answer every question
  • If all else fails, and it’s one of those “percentage” questions, use my
    “85/15 rule.”
    If the issue you are being asked about seems pretty likely, answer “85%.” If it seems unlikely, go with “15%.” It’s usually close enough to the real answer to satisfy.

Bottom line: Pimping is a time-honored tradition in medicine, but should not be considered a rite of passage. There is a real difference in attitudes and learning if carried out properly. Even attendings have a thing or two to learn about this!

Reference: The art of pimping. JAMA. 262(1):89-90, 1989.