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:

• Overtriage: why is it bad?

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

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.

Related post:

• CharityCheck101 – search for charities (put “hospital” or “trauma” in the Organization Name box)
• Clinically insignificant results – if a tree falls in the forest…

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.