Category Archives: General

Jehovah’s Witnesses And Blood Transfusion Demystified

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

  • Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
  • Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
  • Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
  • Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
  • Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
  • Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
  • Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

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Hypothermia And Wound Infection In Trauma

For the most part, hypothermia is a bad thing for trauma patients. Its impact on bleeding and mortality has long been known. A paper just out now implicates it in surgical site infections as well. This fact has already been shown for some types of elective surgery (colorectal), but it appears to be a factor in trauma laparotomy as well.

A retrospective review of 524 patients who underwent a trauma lap looked at the correlation of surgical site infection (SSI) and the depth and duration of hypothermia. The mean low temp across all cases was 35.2° C (!). Nearly a third had at least one measurement below 35° C. About 36% of all patients developed an SSI.

  • Hypothermia is a common problem in these patients!
  • 35 C was the nadir temp most predictive of developing an infection
  • Every degree below 35 C more than tripled the risk of SSI

Bottom line: Yet one more reason to avoid hypothermia in our trauma patients! This effort begins with prehospital providers doing their best to insulate and keep patients warm. The trauma team also has a responsibility to heat up the room and keep the patient covered as much as possible. Baseline temp should be obtained in all major trauma patients. And if they do end up in the operating room, anesthesia needs to monitor the temp closely and keep the surgeon apprised of any concerning drops.

Related posts:

Reference: The Effects of Intraoperative Hypothermia on Surgical Site Infection: An Analysis of 524 Trauma Laparotomies. Annals of Surgery 255(4):789-795, 2012.

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How We Take Care Of Our Elders

Time for some philosophy again. A paper in Neurology released ahead of print confirms something I’m seeing more and more often. Specifically, hospitals can be bad for you, particularly if you are elderly.

The trauma population that we all see is aging with the overall population. Being older predisposes one to injuries that are more likely to require hospitalization. And unfortunately, being in the hospital can have adverse effects. I’m not just talking about the usual culprits such as medical errors or exposure to resistant bacteria. 

The Chicago Health and Aging Project has been tracking a group of elders as they age, and has been making a number of interesting observations. Most recently, they have released information on a correlation between cognitive decline and hospitalization. They tracked nearly 1900 people, of whom 1335 ending up in the hospital for one reason or another (not just trauma). They found that there is a baseline rate of global cognitive decline with age (surprise!). Unfortunately, this rate of decline accelerated 2.4 times in the hospitalized group. Episodic memory scores declined 3.3 times faster, and executive function declined 1.7 times faster. And declines tended to be more pronounced in patients who had more severe illness, longer hospital stay, or advanced age.

There are some issues with the study. It is large, but it is a correlation study nonetheless. Are the effects due to something that happens in the hospital, or are they caused by something not evaluated by the study? It’s also not clear to me whether the declines noted are clinically significant in the daily lives of the people studied, or are just a number on some scale.

Bottom line: Some of the “benign” things that we do to patients in the hospital can have a big impact on their functional outcome. Always remember that they are more fragile than the young trauma patients we take care of. That extra fluid bolus, or dose of morphine, exposure to IV contrast, or noisy neighbor that keeps them from sleeping can make a real difference in how they do. Always consider that everything you do to them might kill them. Then seriously reconsider whether you really, really need to order it at all.


Related post:

Reference: Cognitive decline after hospitalization in a community population of older persons. Neurology, epub ahead of print, March 21, 2012.

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The Handoff: Opportunity for Improvement

Handoffs occur in trauma care all the time. EMS hands the patient off to the trauma team. ED physicians hand off to each other at end of shift. They also hand off patients to the inpatient trauma service. Residents on the trauma service hand off to other residents at the end of their call shift. Attending surgeons hand off to each other as they change service or a call night ends. The same process also occurs with many of the other disciplines involved in patient care as well.

Every one of these handoffs is a potential problem. Our business is incredibly complicated, and given that dozens of details on dozens of patients need to be passed on, the opportunity for error is always present. And the fact that resident work hours are becoming more and more limited increases the need for handoffs and the number of potential errors.

Today, I’ll look at information transfer at the first handoff point, EMS to trauma team. Some literature has suggested that there are 16 specific prehospital data points that affect patient outcome and must be included in the EMS report. How good are we at making sure this happens?

An observational study was carried out at a US Level I trauma center with video recording capabilities in the resuscitation room. Video was reviewed to document the “transmission” part of the EMS report. Trauma chart documentation was also reviewed to see if the “reception” half of the process by the trauma team occurred as well. 

A total of 96 handoffs were reviewed over a one year period. The maximum number of elements in the study was 1536 (96 patients x 16 data elements). The total number “transmitted” was 473, but only 329 of those were “received.” This is not quite as bad as it seems, since 483 points were judged as not applicable by the reviewers. However, this left 580 that were applicable but were not mentioned by EMS. Of the 16 key elements, the median number transmitted was 5, with a range of 1-9. 

This sounds bad. However, the EMS professionals and the physicians have somewhat different objectives. EMS desperately wants to share what they know about the scene and the patient. The trauma team wants to start the evaluation process using their own eyes and hands. What to do?

Bottom line: EMS to trauma team handoffs are a problem for many hospitals. EMS has a lot of valuable information, and the trauma team wants to keep the patient alive. They are both immersed in their own world, working to do what they think is best for the patient. Unfortunately, they could do better if the just worked together a bit more. 

Tomorrow I’ll share a solution to the EMS-trauma team handoff problem.

Related posts:

Reference: Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care 13:280-285, 2009.

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Clearing The Cervical Spine With MRI

If you follow the trauma literature, clearance of the cervical spine in obtunded patients is confusing at best. Although there is some literature out there that suggests that a good cervical CT alone is adequate, I’m not a believer. I’ve seen a case where the radiologist called the scan normal and a good spine surgeon called an injury and was right. So I’m reluctant to use CT alone because the skills of radiologists vary widely. I might be able to believe a dedicated neuroradiologist, but you can’t guarantee one will be reading your patient’s images.

So I fall back on the routine of clearing the bones with a CT scan, and the ligaments with something else. That something else could be a clinical exam (not available in the obtunded patient), flexion-extension images under fluoroscopy (makes a lot of people nervous), keeping the patient in a collar for weeks (skin breakdown), or an MRI. The problem is that there is little guidance in the literature regarding how good MRI is or the best way to use it.

A recent paper in the Journal of Trauma retrospectively looked at 512 out of 17,000 patients (!) seen over 5 years at one trauma center who had both CT and MRI of the c-spine. They wanted to determine if MRI was of any value in cervical spine clearance. Only 150 met the inclusion criteria (GCS<13, no obvious neuro deficit, normal CT). Half of the MRIs were normal. Of the abnormal ones, 81% showed a ligamentous or soft tissue injury. None were deemed unstable and no specific management was needed for any of the abnormal scans.

The authors interpreted their data as showing that MRI provided no additional useful information. However, numbers were (very) small, so the likelihood of them seeing someone with an unstable ligamentous injury was low. Could it be that they showed that MRI detected stable injuries well, and that they could essentially remove the collar based on that?

Bottom line: We still don’t know how to use MRI for clearance. My bias (no good data I can find) is that it is good in suggesting ligamentous injury via nearby edema. If this injury involves only one set of ligaments, it is very likely a stable one and the collar can be removed. If it involves several groups of ligaments, that is probably not the case. And how soon do we have to get the MRI after injury? Some have suggested that 72 hours is the ideal window because edema decreases afterwards. Sounds reasonable, but I can’t find a shred of evidence in the literature. For now, I’ll get an MRI within 72 hours and if it is abnormal, pass the buck to my neurosurgical colleagues so they can gnash their teeth, too.

I would be very happy if someone can help me out and point me towards some good literature on this topic!

Reference: The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography. J Trauma 72(3):699-702, 2012.

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