This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?
One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland Hospital in Dallas. The paper recounted a series of 16 patients who had developed signs and symptoms of lead poisoning (plumbism) after a gunshot or shotgun injury. The common thread in these cases was that the injury involved a joint or bursa near a joint. In some cases the missile passed through the joint/bursa but came to rest nearby, and a synovial pseudocyst formed which included the piece of lead. The joint fluid bathing the projectile caused lead to leach into the circulation.
The patients in the Parkland paper developed symptoms anywhere from 3 days to 40 years after injury. As is the case with plumbism, symptoms were variable and nonspecific. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures to name a few.
Bottom line: Any patient with a bullet or lead shot that is located in or near a joint or bursa should have the missile(s) promptly and surgically removed. Any lead that has come to rest within the GI tract (particularly the stomach) must be removed as well. If a patient presents with odd symptoms and has a history of a retained bullet, obtain a toxicology consult and begin a workup for lead poisoning. If levels are elevated, the missile must be extracted. Chelation therapy should be started preop because manipulation of the site may further increase lead levels. The missile and any stained tissues or pseudocyst must be removed in their entirety.
Reference: Lead poisoning from retained bullets. Ann Surg 195(3):305-313, 1982.
Multidisciplinary Trauma PI Committee is an essential part of all trauma centers verified by the American College of Surgeons. A lot happens in that one hour (or so) meeting. But efficiency hinges on being prepared, and we’ve all experienced meetings where the case presentations just weren’t crisp. Unfortunately, some of the committee members may not have even glanced at the record in advance, and try to catch up during the actual meeting!
What to do? Here’s a set of guidelines to help your presenters do the best job possible. They rely on advance preparation and good communication with your trauma program.
And please comment with your own twists and turns on making trauma PI an efficient and meaningful process!
Trauma call coverage is not always easy to come by, especially at Level III and IV trauma centers and in rural areas. Many centers come to rely on locum tenens surgeons to fill gaps in their call schedules. Unfortunately, this can create quite a few headaches.
There is currently no trauma literature on this topic. Other disciplines, most recently pediatric surgery, have some published suggestions (I hesitate to call them guidelines) for requirements and expectations based on the ACGME core competencies.
Here are some of the nuances that any trauma program needs to recognize if the use of locum tenens surgeons is being considered:
- Board certification – This is a basic tenet of trauma center verification and is absolutely required
- Trauma CME – Recent changes in CME requirements by the American College of Surgeons have nearly eliminated this need. However, do you want a surgeon who does not keep up with trauma education on your call panel? If you allow this, prepare yourself for some interesting performance improvement issues. Make sure that all locums meet some basic requirement for CME or internal education program (IEP) before they start
- Dissemination of committee proceedings – Make sure that this is well-documented. These surgeons must attend at least 50% of your required committee meetings. If they can’t make it, they must be aware of all items discussed, particularly if it involves their care. Use teleconferencing, or at least send them a (confidential) copy of the minutes.
- Responsibility for quality issues – This is the most troubling aspect of using locums. It’s tough to hold one of these surgeons responsible for issues arising from their care if they have left and are never coming back. Make sure there is a mechanism to send feedback about their care even after they are gone for good. And document it well!
Bottom line: In my opinion, the use of locum tenens to cover trauma call gaps is a necessary evil for some centers. They should only be used until a more stable coverage pool is available. The management of quality issues in particular is much more difficult when using roving surgeons. And with the adoption of the new Resource Document (Orange Book), it’s even harder to use them. If you must, use them wisely and only briefly.
Reference: Proposed standards for use of locum tenens coverage in pediatric surgery practices. J Pediatric Surg 48:700-703, 2013 (letter).
Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.
We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.
In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:
- Please introduce yourself to our patient and their family, and explain why you are seeing them.
- Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
- Document your consultation results in writing (paper or EMR) in a timely manner.
- If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
- We round at specific times every day and welcome your attendance and input.
- Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.
Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.