Category Archives: General

Unnecessary Triage To High Level Trauma Centers

Trauma centers and trauma systems are dedicated to getting the right patient to the right hospital at the right time. In the US, The American College of Surgeons (ACS) has set forth criteria for identifying injured patients that should be taken to trauma centers (right patient). The ACS and a number of state authorities have also developed rules for becoming a trauma center (right hospital). Many state authorities have developed additional rules for setting maximum transfer times to the trauma centers (right time).

However, it is possible to short circuit these carefully crafted rules. It has been said (a phrase that indicates some dogma is on the way) that 85% of injured patients can be treated in the local hospital, and that only 15% need transfer to a trauma center. But most Level I and II trauma centers receive transfers from outside hospitals that are less injured than the criteria that would mandate their transfer. 

This is called “secondary overtriage.” A recent study from Dartmouth, which is a rural Level I trauma center, looked at how common this really is. They did a retrospective review of 4796 transfers in to their hospital over a 5 year period. Secondary overtriage was defined as a transferred patient with an ISS<15 and hospital stay <48 hours and no operation. The results are interesting:

  • The hospital treated 7793 patients during the study period, so transfers represented 62% of their activity
  • 24% of adult transfers (1006 patients) and 49% of pediatrics (258 patients) were considered overtriage
  • 216 patients were sent home from the ED (very irritating for families)
  • Half of overtriaged patients arrived on weekends, and 62% arrived between 6PM to 6AM
  • 8% were transferred by air(!)
  • Although Dartmouth received transfers from 72 hospitals (capacities ranged from 6 to 330 beds), 36% of overtriage patients originated from only 5 hospitals

Bottom line: Secondary overtriage is a common occurrence, found in 26% of transfers in this rural trauma center. It is reportedly closer to 40% in urban centers. Whether due to legitimate lack of resources or convenience, they increase the cost of healthcare and inconvenience families. High level trauma centers should monitor for this phenomenon, identify outlier referring facilities, and step up outreach and education to those hospitals to increase their experience and comfort with treating (and keeping) appropriate trauma patients.

Related post:

Reference: Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg Online First June 19, 2013.

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“Medicine Is The Science Of Temporary Truths”

Does anyone know how to write a scientific paper anymore??! My impression is that a majority of articles published in medical journals these days are seriously flawed. Yes, sometimes it’s just not possible to design or execute a study the way it really should be due to scarcity of the data or ethical issues.

But a lot of stuff I read is just not very good. Poor design. Answers to things that no one really cares about. Use of the wrong statistical analysis. And even if the basic ideas and analysis are sound, so many are just not written well.

I believe that it all comes down to poor mentoring. Designing studies and writing scientific papers is an acquired skill that requires a lot of practice. And it’s tough to learn from reading lots of other people’s papers (because they’re not very good). An experienced mentor is invaluable and can accelerate the learning curve.

My own mentors, Charles Lucas and Anna Ledgerwood, taught me by repetition. And lots of it. They told me to read a bunch of papers, then try to emulate them using my own data. I remember turning my first draft in to Dr. Lucas and getting it back a few days letter. The entire thing was covered with scribbling in red pen. Almost none of my original text remained. So I revised it and gave it back. He returned it with a fewer red marks. After many iterations, we finally had a publishable paper!

The most recent Journal of Trauma includes a very nice article on how to construct a good Discussion section in your paper. There aren’t a lot of good articles on the actual technique of medical writing (go figure). But this one is definitely worth reading and will help researchers at any level!

Reference: The anatomy of an article: The discussion section: “How does the article I read today change what I will recommend to my patients tomorrow?” J Trauma 74(6):1599-1602, 2013.

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Contrast Blush in Children

A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush from extravasation.

Splenic contrast blush

This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!

Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!

Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. It should be reserved for cases where nonoperative management is failing, but hypotension (hard fail) has not yet occurred.

The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).

Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.

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How To Lose A Bet And Still Win

I recently made a bet with one of my Emergency Medicine colleagues regarding the outcome of an imaging study. The bet was that the results of the study would be negative from a trauma standpoint. The actual outcome was that the result showed a positive but clinically insignificant result.

So I lost, right? I don’t think so! How did I actually win? The bet was a monetary one ($100). The key to winning is where the money actually goes. No pizza and beer here. Most hospitals, and a few trauma programs, are associated with a charitable foundation. My pediatric trauma program is linked to one for each of the two hospitals that comprise it (Regions Hospital Foundation and Gillette Children’s Specialty Healthcare Foundation). I wrote a check to one of them, and specified the donation be earmarked for the pediatric trauma program.

Bottom line: Always be a winner! You don’t need to make bets to contribute to charitable foundations, either. Encourage your colleagues (or patients) to contribute to your hospital’s charitable foundation, and let them know that they can direct their donation to whichever program they (or you) suggest.

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Pulmonary Edema After Chest Tube Insertion

Re-expansion pulmonary edema is an uncommon event after chest tube insertion. Typically, patients have had symptoms of pneumothorax for several days, usually 3 or more. It occurs most often if a large amount of air (or blood) is evacuated at once. The patient will typically become symptomatic within an hour, with decreased oxygen saturation and subjective breathing difficulty.

Although the mechanism is not entirely clear, it appears that the small blood vessels in the lung become more permeable if they are collapsed for an extended period. Mechanical stress from rapid re-expansion further damages the vessels, allowing them to leak. This leads to oxygenation and ventilation problems if severe. 

Practical tips:

  • Check the history. Most of these patients have had their pneumothorax for 3 or more days.
  • Check the xray. Complete pneumothorax (or large hemothorax) puts the patient at high risk.
  • Modify your chest tube insertion technique. Clamp the distal end of the tube so the pneumothorax is not evacuated suddenly as the tube goes in.
  • Modify the collection system. Do not use suction initially; only set up for water seal. Clamp the tubing on the patient side. Every 10-15 minutes release the clamp and briefly let some of the air out of the chest, then reclamp. Repeat this until all air has bubbled through the water seal chamber. 
  • Watch your patient. If they cough excessively, start to desaturate or become dyspneic, get your respiratory adjuncts. Give higher inspired oxygen by appropriate means, and consider BiPap or CPAP. In extreme cases intubation may be needed. If the patient does not have any difficulties after about an hour, connect the collection system to suction and proceed as you normally would.

Reference: Reexpansion pulmonary edema. Ann Thoracic Cardiovasc Surg 14:205-209, 2008.

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