Category Archives: General

The Tertiary Survey For Trauma: Residents vs APPs

This is the final installment of my series on the tertiary survey for trauma.  For years, this exam was performed by trauma surgeons or residents. However, over the years advanced practice providers (APPs) such as physician assistants and nurse practitioners have become more common in trauma. It is now commonplace for these providers to participate on the trauma service, perform procedures, and document examinations such as the tertiary survey.

But until now, no one has compared the accuracy of this exam when performed by a physician vs an APP. One would assume that the results should be the same, but as we’ve seen time and time again, common sense doesn’t always pan out. A group at the Royal Brisbane and Women’s Hospital in Queensland, Australia tried to answer this question using a retrospective review of their experience.

This busy trauma center admits about 2,250 patients per year, and began to employ clinical nurse consultants on the trauma service nearly ten years ago. Since there was no formal trauma curriculum for these nurses, they were required to complete the Trauma Nursing Core Curriculum (TNCC) or an equivalent prior to hire. The nurses were supervised by one of the trauma / emergency physicians.

For this study, 165 patients who underwent a tertiary survey by both an emergency medicine resident and a trauma nurse over a three year period were reviewed. The surveys were typically performed within 24 hours of admission to a ward bed or 24 hours before transfer from ICU to the ward. Typically, the resident and nurse tertiary surveys were performed within 30 minutes of each other to avoid any effects from injury progression.

All missed injuries were graded for severity by an attending physician using the Clavien-Dindo system. Here’s what it looks like:

And here are the factoids:

  • A total of 3,065 patients had a tertiary survey performed during the study period, but only 165 had it performed by both a resident and an APP
  • Based on their surveys, additional investigations were ordered in 35 patients, 14 by the trauma nurse, 11 by the resident, and 10 by both
  • Eight of 14 studies ordered by the nurse identified a missed injury, two of 11 studies ordered by the resident did, and two were identified in the studies ordered by both
  • Of the 12 identified missed injuries, the Clavien-Dindo (C-D) score was 0 in one, I in ten patients, and III (required surgery) in one
  • The nurses identified a higher number of missed injuries (10 of 24) than the residents (4 of 21) without significantly increasing the number of tests ordered

The authors concluded that performance of the nurses was similar to that of the house officers.

Bottom line: Maybe the authors were trying to be gentle on their residents. But it looks to me like the trauma nurses did a much better job of finding occult injuries. I wish the authors had broken down the C-D scores to see which group identified the score III patient.

To be fair, this study has some significant limitations. Out of more than 3,000 eligible patients, only 165 had a dual tertiary survey. So the sample may not be representative. But the results were impressive enough that I would speculate the results of a larger group may be similar.

So I think it is safe to assume that APPs (specifically nurse practitioners, but this can probably be generalized to physician assistants as well) can do a tertiary survey just as well as a resident. And possibly better!

Reference: Trauma tertiary survey: trauma service medical officers and trauma nurses detect similar rates of missed injuries. J Trauma Nursing 28(3):166-172, 2021.

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The Tertiary Survey For Trauma: Does It Work?

Here’s the second part in my series on the tertiary survey for trauma. In my last post I discussed the basics, and in the next and final one I’ll review who can do it.

Delayed diagnoses / missed injuries are with us to stay. The typical trauma activation is a fast-paced process, with lots of things going on at once. Trauma professionals are very good about doing a thorough exam and selecting pertinent diagnostic tests to seek out the obvious and not so obvious injuries.

But we will always miss a few. The incidence varies from 1% to about 40%, depending on who your read. Most of the time, they are subtle and have little clinical impact. But some are not so subtle, and some of the rare ones can be life-threatening.

The trauma tertiary survey has been around for at least 30 years, and is executed a little differently everywhere you go. But the concept is the same. Do another exam and check all the diagnostic tests after 24 to 48 hours to make sure you are not missing the obvious.

Does it actually work? There have been a few studies over the years that have tried to find the answer. A paper was published that used meta-analysis to figure this out. The authors defined two types of missed injury:

  • Type I – an injury that was missed during the initial evaluation but was detected by the tertiary survey.
  • Type II – an injury missed by both the initial exam and the tertiary survey

Here are the factoids:

  • Only 10 observational studies were identified, and only 3 were suitable for meta-analysis
  • The average Type I missed injury rate was 4.3%. The number tended to be lower in large studies and higher in small studies.
  • Only 1 study looked at the Type II missed injury rate – 1.5%
  • Three studies looked at the change in missed injury rates before and after implementation of a tertiary survey process. Type I increased from 3% to 7%, and Type II decreased from 2.4% to 1.5%, both highly significant.
  • 10% to 30% of missed injuries were significant enough to require operative management

Bottom line: In the complex dance of a trauma activation, injuries will be missed. The good news is that the tertiary survey does work at picking up many, but not all, of the “occult” injuries. And with proper attention to your patient, nearly all will be found by the time of discharge. Develop your process, adopt a form, and crush missed injuries!

Reference: The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med 20:77, 2012.

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The Tertiary Survey for Trauma: The Basics

I’m posting a three part series on the trauma tertiary survey. Today, I’ll cover the basics. In the next two posts I’ll dig into how well it works and who can do it.

Major trauma victims are evaluated by a team to rapidly identify life and limb threatening injuries. This is accomplished during the primary and secondary surveys done in the ED. The ATLS course states that it is more important for the team to identify that the patient has a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration). However, once the patient is ready for admission to the trauma center, it is desirable to know all the diagnoses.

This is harder than it sounds. Physical examination tends to direct diagnostic testing, and some patients may not be feeling pain, or be awake enough to complain of it. Injuries that are painful enough may distract the patient’s attention away from other significant injuries. Overall, somewhere between 7-13% of patients have injuries that are missed during the initial evaluation.

A well-designed tertiary survey helps identify these occult injuries before they are truly “missed.” This survey consists of a structured and comprehensive re-examination that takes place within 48-72 hours, and includes a review of every diagnostic study performed. Ideally, it should be carried out by two people: one familiar with the patient, and the other not. It is desirable that the examiners have some experience with trauma (sorry, medical students).

The patients at highest risk for a missed injury are those with severe injuries (ISS>15) and/or impaired mental status (GCS<15). These patients are more likely to be unable to participate in their exam, so a few injuries may still go undetected despite a good exam.

I recommend that any patient who triggers a trauma team activation should receive a tertiary survey. Those who have an ISS>15 should also undergo the survey. Good documentation is essential, so an easy to use form should be used. Click here to get a copy of our original paper form. We have changed over to an electronic record, and have created a dot phrase template, which you can download here.

In my next post: Does the tertiary survey actually work?

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Fatigue IV: Trauma Surgeons And Residents

The effects of fatigue on the surgeon have been looked at a number of times over the years. Most of this work focuses on resident physicians, however. Another problem with the majority of these studies is that they did not test the surgeon or resident on tasks that reflect real life practice.

A study from Arizona State University used a laparoscopic simulation that tested both psychomotor and cognitive skills that would be called on during real surgical procedures. In addition to the purely manual task of stacking varied sizes of rings using laparoscopic instruments, exercises were developed and validated that tested attention, tracking and other critical components. Monitored parameters included hand and tool movement, smoothness and economy of motion, and time required to complete the task. An overall proficiency score was calculated.

Five residents and nine attending physicians were tested. They were all given 4 practice sessions with the simulator before the study began. Sleep hours and caffeine use during call were recorded using a questionnaire. Each individual was then tested three times prior to being on call and three times post-call.

As would be expected, attending surgeons showed higher proficiency scores than residents both pre-call and post-call. However, both groups experienced significant declines in proficiency and significant increases in cognitive errors post-call. Interestingly, attending surgeons made 25% fewer cognitive errors post-call when compared to residents, and their psychomotor skills were unchanged. This suggests that the attendings were focused on skills at the expense of decision making.

Two other interesting items from this paper:

  • Errors increased exponentially with subjective reported fatigue in the attending surgeons. This means that a small amount of attending surgeon fatigue led to a large increase in errors. The implication is that the older attendings had less reserve, and that their greater skills and experience could be quickly overwhelmed.
  • Caffeine intake had no effect on motor skills or cognitive errors.

Bottom line: Fatigue from post-call sleep deprivation impedes psychomotor and cognitive functions, as well as performance. Residents are affected more than attending surgeons, but attending performance declines more rapidly as they grow fatigued. As any post-call surgeon knows, activities the day after call should be limited to the mundane to optimize patient safety.

In the next installment, we’ll look at the impact of poor sleep on our patients!

Reference: The effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons. Am J Surg 196(6):8133-820, 2008.

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Fatigue III: Impact On Nurses

Although 8-hour shifts are the most common work arrangement around the country in all most occupations, they are a bit less common in nursing. Nurses have work and sleep patterns equivalent to prehospital providers. And critical care nurses probably have the most variable and punishing work patterns.

One may think that just increasing to a 12-hour shift is not that big of a deal. The nursing school at the University of Auckland performed their own survey of ICU nurses in two separate hospitals in New Zealand. They administered the Occupational Fatigue Exhaustion/Recovery Scale and evaluated differences in relation to a number of demographic variables.

Here are the factoids:

  • There were a total of 67 participants in the two hospitals and all worked 12-hour shifts.
  • Nurses at one hospital (A) worked mostly day or mostly night shifts and tended to be younger. Shifts were more mixed at the other (B).
  • About half of the nurses reported low to moderate fatigue acutely, and two thirds re-ported this level between shifts as well.
  • Factors that correlated with increased fatigue were younger age, fewer children, less years of experience, and less exercise.
  • Higher fatigue levels were reported at hospital A, which had the younger, less experienced nurses.

Bottom line: This is another survey study, but it does illustrate some common issues. Some factors could be changed by rearranging the shift structure to all day or all night shifts. Exercise was associated with less stress and could be encouraged. But the nature and pace of work in the ICU remains constant and is difficult to control for. Some strategies for positive change are listed on the next page of the newsletter.

In my next post, I’ll review the impact of sleep problems on trauma surgeons and residents.

Reference: Exploring the impact of 12-hour shifts on nurse fatigue in intensive care. Applied Nurs Res 50:151191, Dec 2019.

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