Does The Color Of Your Scrubs Matter?

In most hospitals, it seems that workers in every department wear a different color of scrubs. Traditionally, surgeons have worn scrubs in darker shades of green or blue. This is not always true, as some hospitals have adopted crazy colors in order to reduce theft. Apparently, not too many people are comfortable wearing a pilfered pair of bright pink scrubs in public.

We know that color can have subliminal impacts on people. Blue tends to have a calming effect. This is one of the reasons that police officer uniforms are frequently this color. Green and blue also tend to be associated with medicine. Red, orange,  and yellow are often associated with food. Ever wonder why McDonald’s arches are the color they are?

But what about scrubs? Patients do tend to form associations between a clinician’s dress and their intelligence, empathy, and trustworthiness. Interestingly, scrubs (as opposed to dress clothes) score high for all of these.

But what about the rainbow of colors that scrubs are available in? A recent research letter was submitted to JAMA Surgery by a group at UNC Chapel Hill. They administered an electronic survey over a two-month period to adult patients and visitors at their university hospital.  Their goal was to determine whether scrub color influenced the perception that the wearer was a surgeon, and what character traits were perceived.

This is a copy of the survey, asking for the identification of the surgeon, and the most skilled individual based on scrub color.

The results were quite interesting. This is a chart of trait identification based on color for men. The chart for women was very similar. Note that taller bars are a negative.

Here are the factoids:

  • Half of participants were 30-60 years old, and the remainder were evenly split between younger and older people
  • Green was the color most associated with surgeons and was selected by nearly half of participants. Sex did not seem to matter.
  • Black had the most negative connotation of any color
  • Blue scrubs were associated with the most caring clinicians; however it also implied that they were less knowledgeable, less skilled, and less trustworthy

Bottom line: This is an intriguing little study that shows that unfortunately, looks do matter. Even the colors of our clothes do! The participants associated black with death and said they looked like a mortician’s uniform. So definitely avoid!

The poor perception of clinicians wearing green scrubs is difficult to explain, but consistent. The navy and blue characteristics were generally positive and don’t look appreciably different from each other.

Hospitals pay little attention to the color of the scrubs they purchase. But this choice may have an impact on how the wearer is perceived by patients and families. Perhaps it is time to rethink color in patient-facing clinicians. And avoid black scrubs like the plague!

Reference: Association Between Patient Perception of Surgeons
and Color of Scrub Attire. JAMA Surg, 2023 Jan 11. doi: 10.1001/jamasurg.2022.5837. Epub ahead of print. PMID: 36630142.

In The Next Trauma MedEd Newsletter: Interesting Stuff

The January issue of the Trauma MedEd newsletter will be sent out soon! It’s chock full of general stuff of interest to all you trauma professionals.

This issue is being released Sunday evening. If you sign up any time before then, you will receive it, too. Otherwise, you’ll have to wait until it goes out to the general public at the end of next week. Click this link right away to sign up now and/or download back issues.

In this issue, get some tips on:

  • Nonsurgical Admissions And The Nelson Score
  • Tip: Evaluation of Hematuria in Blunt Trauma
  • Central Lines Cause Hypercoagulability?
  • Lab Values From Intraosseous Blood
  • Leukocytosis After Splenic Injury

As always, this month’s issue will go to all of my subscribers first. If you are not yet one of them, click this link right away to sign up now and/or download back issues.

Cool Discovery: Bones Have Lymphatics!

The lymphatic system is a network of vessels that helps regulate fluid homeostasis, waste clearance, and immune response. Most tissues in the body have some type of lymphatic drainage. The main holdouts have been the brain, the eyes, and our bones.

Ten years ago, the brain lymphatic system (called glymphatics since they are associated with neuroglial cells) was discovered. This system is critically important to brain health. During deep sleep, our neurons shrink in size, allowing CSF to flush through the glymphatic system. This sweeps the accumulated debris (including tau and beta-amyloid) out through the glymphatics to be disposed of.

In 2014, Schlemm’s canals in the eye were also identified as functioning as a lymphatic system. These collect the aqueous humor absorbed by the trabecular meshwork on the surface of the iris.

And now, the Institute of Molecular Medicine at Oxford has discovered a lymphatic network in our bones! As anybody who has played with a microscope can attest, it’s easy and fascinating to view soft tissues. But working with calcified tissue is very challenging. For this reason, the organization of blood vessels in bone has been difficult to observe.

The authors used light sheet fluorescence microscopy to image intact bone specimens. This technique shines a sheet of laser light through a labeled specimen. A fluorescence detector perpendicular to the sheet of light records light output from the tagged items of interest in one two-dimensional layer. This technique can actually be used in living specimens, although in this study the bones were prepped and the calcium was carefully removed.

The authors identified lymphatics in mouse and human bone specimens. They also found that these lymphatics expanded in response to stress, which resulted in formation of more lymphatics. This, in turn, induced regeneration of the bone itself and hemopoietic cells in the bone marrow. However, as the animals aged, their lymphangiogenesis lessened, which may explain why bones in the elderly do not heal as well or as quickly.

Bottom line: This is an exciting discovery using a novel imaging technique. It showed not only the structure of these lymphatics but also their role in healing from injury. It raises the interesting possibility that manipulating the lymphatic endothelial cells might allow us to accelerate healing after injury.

First, we had lymphatics. Then, when they were found in the brain, we called them “glymphatics.” So now I will take the prerogative to name the ones discovered in bone as “blymphatics.” Not very sexy, but you get the idea!

Reference: Lymphatic vessels in bone support regeneration after injury. Cell. 2023 Jan 19;186(2):382-397.e24. doi: 10.1016/j.cell.2022.12.031. PMID: 36669473.

Best Of EAST 2023 #12: VTE Prophylaxis In Severe TBI

Time for another abstract on venous thromboembolic disease (VTE) prophylaxis, but this time in patients with severe head injury. VTE is a significant problem for trauma patients. Those with a potential source of bleeding from their injuries cause us to hesitate and consider the timing of chemical prophylaxis closely. Do we really want to cause more bleeding?

This is particularly problematic with intracranial hemorrhage, as the treatment is major brain surgery. Over recent years, the literature has been leaning toward earlier prophylaxis as soon as the intracranial blood has stopped evolving.

The EAST Multicenter Trials Group performed a seven-year retrospective review at 24 Level I and II trauma centers to assess the safety and efficacy of VTE chemoprophylaxis.  They divided patients into three groups: no prophylaxis, early prophylaxis (within 24 hours), and late prophylaxis (after 24 hours).

The authors assessed two endpoints: VTE occurrence and expansion of intracranial hemorrhage (ICH). They used several regression models to check their hypotheses.

Here are the factoids:

  • A total of 2,659 patients met the inclusion criteria. This averages out to 15 eligible patients per month per center. This is probably reasonable when combining a few high-volume centers with more lower volume centers.
  • Compared to early prophylaxis, patients who received late prophylaxis were twice as likely to develop VTE, although this was not statistically significant (p = 0.059)
  • Compared to early prophylaxis, patients who received no prophylaxis were a third less likely to develop VTE, although this, too, was not statistically significant (p = 0.39
  • About 25% of patients who received either early or late prophylaxis suffered an extension of their ICH, but only 17% of the no-prophylaxis group did
  • The regression model showed that the no prophylaxis group was 36% less likely to develop ICH extension compared to either early or late prophylaxis groups.

The workgroup concluded that the development of VTE was not dependent on the timing of the start of prophylaxis. Furthermore, patients who did not receive any prophylaxis had significantly decreased odds of ICH extension. The group recommended larger randomized studies to extend this work.

Bottom line: Shocker! This multicenter study suggests that the no prophylaxis and early prophylaxis groups had fewer VTE events than the late group, although these results were not statistically significant. This means that there wasn’t an advantage to giving the shot.

And the other major conclusion was that both early and late prophylaxis was associated with a significantly higher incidence of ICH extension. 

Roll these together, and you will find that neither early nor late prophylaxis help prevent VTE, yet they are both associated with additional bleeding in and around the brain! 

Heresy! I am trying to figure out what to make of these results. Perhaps the retrospective nature of the study and the wildcards this introduces influenced the results. It could be a study power problem, except the numbers were approaching significance that was unfavorable for prophylaxis.

I will be very interested to hear how the authors explain these findings. And yes, a well-powered randomized study would be great, but I don’t think many institutional review boards will be keen on a no-treatment group given our current fear of VTE. So don’t count on any real answers soon.

Reference: EARLY VTE PROPHYLAXIS IN SEVERE TRAUMATIC BRAIN INJURY: A PROPENSITY SCORE WEIGHTED EAST MULTICENTER TRIAL. EAST 2023 Podium paper #38.

Best Of EAST 2023 #11: Prehospital Use Of TXA

More stuff on TXA! I published two posts back in December on TXA hesitancy. This Friday, the trauma group at Wake Forest is presenting an abstract on TXA use by prehospital trauma professionals.

It is very likely that EMS carries tranexamic acid (TXA) in your area. Each agency has its own policy on when to administer, but the primary indication is hemorrhagic shock. A few ALS services may infuse for serious head injury as well.

The Wake Forest group was concerned that TXA administration might be occurring outside of the primary indication, hemorrhagic shock. They reviewed their experience using a six-year retrospective analysis of their trauma registry. The patients’ physiologic state before and after arrival at the hospital was assessed, as were the interventions performed in both settings.

Here are the factoids:

  • Of 1,089 patients delivered by 20 EMS agencies, one-third (406) had TXA initiated by EMS
  • Only 58% of patients who received prehospital TXA required transfusion after arrival
  • TXA administration based on BP criteria were as follows:
  • Similar compliance was noted when examining only high-volume EMS services

The authors concluded that TXA use is common in the prehospital setting but is being used outside of literature-driven indications.

Bottom line: This is an interesting snapshot of TXA use surrounding a single Level I trauma center. As such, it can’t be automatically applied to all. However, my own observations suggest that this drug is being used more liberally nationwide.

Clearly, the prehospital providers are starting TXA on patients who do not fit the category of severe hemorrhagic shock. Only 30% of patients receiving it had SBP < 90. Is this a bad thing? Referring back to my conversation on TXA hesitancy, I think not. But do keep in mind that giving any drug when not indicated adds no benefit and can certainly increase risk. The good news is that TXA is very benign when it comes to side effects.

However, policies are designed for a reason: safety. And if the EMS agency policy says to give TXA only for SBP < x, then that’s when it should be given. The prehospital PI process (or the trauma center’s) should identify variances and work to correct them. If EMS is “overusing” TXA in your area, your trauma center should add this as a new prehospital PI filter and let them know when it happens.

Here are my questions and comments for the presenter/authors:

  • Is using the need for transfusion a valid measure of the need for TXA? You found that half of the patients receiving TXA were not transfused. The decision to transfuse depends on surgeon preference, and they don’t always use objective criteria. And hey! Maybe the TXA worked, obviating the need for blood!

This is a straightforward and intriguing paper. I’m excited to hear more details on how you sliced and diced this data.

Reference: ARE DATA DRIVING OUR AMBULANCES? LIBERAL USE OF TRANEXAMIC ACID IN THE PREHOSPITAL SETTING. EAST 2023 Podium paper #34.

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