Category Archives: General

What To Do? Small Hospital, Unstable Patient

February 12, 2013 The Trauma Pro Leave a comment

It’s the situation that physicians in smaller hospitals dread. A major trauma patient gets dropped off at the door. You do your evaluation, quickly determining that they need services that you don’t just have (head injury and positive FAST in the abdomen, let’s say). You call your community EMS service to transport to a Level I trauma center, which is about 30 minutes away by ground. And just as they are rolling out the door to the rig, the blood pressure drops to 60! What to do?!

The ATLS course is very clear, and very correct. Back into the ED for a quick re-evaluation. The most common cause for a significant disturbance in vitals or exam lies within the primary survey. You will almost always find a problem with Airway, Breathing, or Circulation. (A Disability problem can cause a problem on rare occasion (hypotension from impending herniation), but there’s not much that you can do about it, really. Hyperventilate, hyperosmolar therapy, okay but probably a poor outcome for the patient anyway.)

So you didn’t find any airway or breathing issue. But the abdominal stripe(s) you saw on FAST are larger, so it’s circulation. Now what? And does it matter if you have a surgeon available on call? The answer is simpler than you think.

ATLS says that, if you have surgical support available you have to use it in this type of situation. If you don’t have it, package the patient with a lot of blood and plasma and send. If you have a physician or nurse to spare you could consider sending them along to help during transport, but for small community hospitals this is not practical.

But if you do have a surgeon, does it make sense to use them? Not always! You must take into account response times and transport times. Let’s say it’s 2:00 am and you call your surgeon for this hypotensive patient. They may take up to 30 minutes to get in and see the patient. They then agree that the patient needs a laparotomy and she proceeds to call in the OR team. Yet another 30 minutes tick by. Will the patient still even be alive when they roll into the OR?

Or you could just put the patient back in the ambulance (air preferably, but ground if you have to) and get them to your trauma center quickly. They can then be whisked directly into a waiting OR in less than 30 minutes from your door. This is probably the ideal solution here. Obviously this doesn’t work as well if you are a few hours away from your resource trauma center.

Bottom line: Deciding what to do with a patient that needs urgent treatment that you can’t immediately deliver is tough! That’s why it’s always a calculus problem when you’re faced with this situation. But take all of the response and transport times into account, and do what’s best for your patient!

Thanks to EM Res for posing this question!

General

Above-Knee vs Below-Knee DVT

February 11, 2013 The Trauma Pro Leave a comment

Deep venous thrombosis (DVT) is a common problem in trauma patients. Many trauma centers have developed practice guidelines for beginning mechanical or chemoprophylactic measures as soon as practical in patients at risk. Some believe that below-knee and above-knee DVT are different, with those located below the knee posing a lower risk for propagation and pulmonary embolism. As always, we need to know, is it true?

The group at Oregon Health and Science University performed a retrospective review of six years of their experience with lower extremity DVT. They identified 308 patients who developed this complication and noted the following interesting findings:

Two thirds developed below-knee DVT, one third above-knee
Overall rate of pulmonary embolism (PE) was about 4% overall
PE occurred with equal frequency in below-knee vs above-knee DVT
The rate at which DVT resolved was no different in patients receiving prophylactic doses of enoxaparin vs therapeutic dosing
Below-knee DVT did not resolve faster than above-knee. Thus they are not more likely to resolve spontaneously

The point of looking for and giving enoxaparin and similar drugs in trauma patients is to avoid DVT, limit it’s progression, and prevent PE. This study showed that there really is no difference between below-knee and above-knee DVT, and that they should be treated similarly. Unfortunately, it also showed that prophylactic and therapeutic management worked equally as well. This is probably due to the fact that there are major differences across various types of trauma patients and that we still don’t know how to calculate the right dose of enoxaparin. However, we do have some tools to help us make a better guess.

Bottom line: Trauma patients with any lower extremity DVT need to be treated, and enoxaparin is a common way to do this. Below-knee vs above-knee does not matter. If enoxaparin is used, just selecting a therapeutic dose (e.g. 1mg/kg bid) is not enough. Monitoring with anti-factor Xa levels or thromboelastogram (TEG) may help optimize effectiveness and reduce risk of PE.

Reference: The effects of location and low-molecular-weight heparin administration on deep vein thrombosis outcomes in trauma patients. J Trauma 74(2):476-481, 2013.

General

The Two-Sheet Trauma Trick

February 7, 2013 The Trauma Pro Leave a comment

Hypothermia is always a concern in trauma patients. Even the simple act of completely exposing your patient in the trauma room facilitates it. How do trauma professionals balance the need to see everything with the equally important need to keep the patient warm?

The natural reaction is to cover them up. Sheets and warm blankets are the usual tools. But I always marvel that, as soon as the blanket goes on, there’s always a need to examine something or do some procedure. Look at a wound. Insert a urinary catheter. And every time this happens, the blanket comes off.

Here’s a clever way to deal with this problem. Don’t use just one sheet or blanket. Use two! Fold each one in half, so they are each half-length. Place one on the top half of the patient, the other at the bottom, overlapping slightly at the waist. If you need to look at an extremity, fold the blanket that covers it over from right to left (or left to right) to uncover just the area of interest. To insert a urinary catheter, just open the area at the waist, moving the top sheet up a little, the bottom down a little.

Bottom line: Keep your patient toasty! Use the two-sheet (or warm blanket) trick to avoid hypothermia. Remember, patient temperature begins to drop as soon as the clothes come off! And I don’t recommend the use of one-piece inflatable warming blankets (e.g. Bair Hugger) until the work in the ED is complete, because the whole thing has to be removed every time you need meaningful access to the patient.

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General

Trauma Care And HIPAA Demystified

February 5, 2013 The Trauma Pro Leave a comment

HIPAA

There is a lot of confusion and misinformation out there regarding HIPAA (Health Insurance Portability and Accountability Act). This law was enacted in 1996 with the intent of protecting the health insurance benefits of workers who lose or change their jobs, providing standards for electronic health care transactions, and protecting a patient’s sensitive health information. This last part has caused much grief among trauma professionals.

It is commonplace for a trauma patient to require the services of many providers, from the initial prehospital crew, doctors and nurses at the initial hospital, yet another ambulance or aeromedical crew, professionals at a receiving trauma center, rehab or transitional care providers, and the patient’s primary physician to name a few. Unfortunately, because there can be significant financial penalties for violating the HIPAA privacy guidelines, providers are more likely to err (incorrectly) on the side of denying information to others outside their own institution.

All of the people mentioned above are considered “covered entities” and must abide by the HIPAA Privacy Rule. This rule allows us to release protected information for treatment, payment and “health care operations” within certain limits. The first and last items are the key provisions for most trauma professionals.

Treatment includes provision, coordination and management of care, as well as consultations and referrals (such as transferring to a trauma center). Think of this as the forward flow of information about your patient that accompanies them during their travels.

Health care operations include administrative, financial, legal and quality improvement activities. These quality improvement activities depend on the reverse flow of information to professionals who have already taken care of the patient. They need this feedback to ensure they continue to provide the best care possible to everyone they touch.

Bottom line: Trauma professionals do not have to deny patient information to others if they follow the rules. Obviously, full information must be provided to EMS personnel and receiving physicians when a patient is transferred to a trauma center. But sending information the other way is also okay when used for performance improvement purposes. This includes providing feedback to prehospital providers, physicians, and nurses who were involved in the patient’s care at every point before the transfer. The key is that the information must be limited and relevant to that specific encounter.

Feedback letters and forms, phone conversations and other types of communications for PI are fine! But stay away from email, which is not secure and is usually a violation of your institutional privacy policies.

Always consult your hospital compliance personnel if you have specific questions about HIPAA compliance.

Reference: HIPAA Privacy Rule

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