Category Archives: General

Flying Or Diving After Traumatic Pneumothorax: Part 2

March 17, 2023 The Trauma Pro Leave a comment

In my last post, I wrote about the accepted management of and delay in flying due to traumatic pneumothorax. I republished the post because of the publication of a paper from Oregon Health Science University in Portland. The authors specifically tried to assess timing of chest tube removal and long-distance flight, and to measure the risk of pneumothorax recurrence or other complications.

The authors performed a retrospective review of a series of military patients who had sustained chest injuries that were treated with chest tubes over a 5 year period from 2008 to 2012. After tube removal and a pneumothorax-free period of at least 24 hours (by chest x-ray), the patients were then transported by air from the military theater back to the United States.

Here are the factoids:

Of 517 patients screened in the military trauma registry database, only 73 were available for study after applying exclusion criteria
Subjects were predominantly young and male, as one would expect from the injured military population, and 74% were injured by a penetrating mechanism
Median time that the chest tube was in place was 4 days, and median time from tube removal to flight was 2.5 days
All patients had post-flight documentation available for review, but only half (37) had in-flight documentation available
Nearly half (40%) had positive pressure ventilation in place during the flight
Five patients had “in-flight medical concerns” (4 were ventilated), but none were related to the pneumothorax. The four ventilated patients had ventilator issues, the non-vented patient had “self-limited discomfort without evidence of respiratory distress.”
None of the subjects developed a recurrent pneumothorax, either post-flight or over the following 30 days

The authors conclude that air travel after tube removal and a 24-72 hour observation period “appears safe.”

Bottom line: Not so fast! This is yet another small, retrospective study making grand claims. The study group is a very unique population: healthy, fit young men with penetrating injury. Your average civilian trauma patient is older, less healthy, and usually has a blunt mechanism with multiple rib fractures. In-flight documentation was not available in half of the cases. And a full medical team was present on the aircraft had a problem actually occurred.

Contrast this with a civilian patient on a commercial aircraft with very limited medical equipment and expertise on board. What could go wrong? I definitely do not recommend changing our practice on these patients yet based on this one paper. Until we have better guidance (more good papers) stick to the usual wait time to ensure a safe flight for your patient.

Reference: Trauma patients are safe to fly 72 hours after tube thoracostomy removal. J Trauma, published ahead of print, May 18 2018.

General

Does The Color Of Your Scrubs Matter?

January 31, 2023 The Trauma Pro Leave a comment

In most hospitals, it seems that workers in every department wear a different color of scrubs. Traditionally, surgeons have worn scrubs in darker shades of green or blue. This is not always true, as some hospitals have adopted crazy colors in order to reduce theft. Apparently, not too many people are comfortable wearing a pilfered pair of bright pink scrubs in public.

We know that color can have subliminal impacts on people. Blue tends to have a calming effect. This is one of the reasons that police officer uniforms are frequently this color. Green and blue also tend to be associated with medicine. Red, orange, and yellow are often associated with food. Ever wonder why McDonald’s arches are the color they are?

But what about scrubs? Patients do tend to form associations between a clinician’s dress and their intelligence, empathy, and trustworthiness. Interestingly, scrubs (as opposed to dress clothes) score high for all of these.

But what about the rainbow of colors that scrubs are available in? A recent research letter was submitted to JAMA Surgery by a group at UNC Chapel Hill. They administered an electronic survey over a two-month period to adult patients and visitors at their university hospital. Their goal was to determine whether scrub color influenced the perception that the wearer was a surgeon, and what character traits were perceived.

This is a copy of the survey, asking for the identification of the surgeon, and the most skilled individual based on scrub color.

The results were quite interesting. This is a chart of trait identification based on color for men. The chart for women was very similar. Note that taller bars are a negative.

Here are the factoids:

Half of participants were 30-60 years old, and the remainder were evenly split between younger and older people
Green was the color most associated with surgeons and was selected by nearly half of participants. Sex did not seem to matter.
Black had the most negative connotation of any color
Blue scrubs were associated with the most caring clinicians; however it also implied that they were less knowledgeable, less skilled, and less trustworthy

Bottom line: This is an intriguing little study that shows that unfortunately, looks do matter. Even the colors of our clothes do! The participants associated black with death and said they looked like a mortician’s uniform. So definitely avoid!

The poor perception of clinicians wearing green scrubs is difficult to explain, but consistent. The navy and blue characteristics were generally positive and don’t look appreciably different from each other.

Hospitals pay little attention to the color of the scrubs they purchase. But this choice may have an impact on how the wearer is perceived by patients and families. Perhaps it is time to rethink color in patient-facing clinicians. And avoid black scrubs like the plague!

Reference: Association Between Patient Perception of Surgeons
and Color of Scrub Attire. JAMA Surg, 2023 Jan 11. doi: 10.1001/jamasurg.2022.5837. Epub ahead of print. PMID: 36630142.

General

How To Avoid Missed Injuries

November 29, 2022 The Trauma Pro Leave a comment

I’ve just spent two days here looking at the phenomenon of “delayed diagnosis” or missed injury. I believe that there are only two fundamental reason why this occurs:

Insufficient diagnostic technique – A good physical exam and/or specific diagnostic techniques were not performed. Or rarely, the injury cannot be readily detected by existing techniques and technology. The former is usually the real problem, and may be an issue with either the physical exam completeness and/or technique, or judgment used to obtain the appropriate diagnostic test. Example 1: a penetrating injury to the back is missed because the patient is not logrolled to examine this area. Example 2: a spine fracture is missed in an elderly patient with a fall from standing because the back pain found on physical exam is evaluated only with conventional imaging of the spine, not CT.
Failure to recognize the injury – The injury was actually identified on a test, but was not appreciated by the clinician. Example 1: the radiologist may not have appreciated and reported out a subtle anomaly in the cervical spine imaging. Example 2: you fail to check you patient’s lab tests and miss a sudden spike in serum amylase or lipase the day after your patient was kicked in the epigastrium by a horse.

So what can you do to avoid this potential problem? Here are some tips:

Admit that it can really happen to you. If the missed injury rate at your center is off the low end of the bell curve (< 5%) then you are either really good or really blind. You’d better take a close look at your performance improvement process, because you may be fooling yourself.
Adopt a firm definition of “delayed diagnosis.” Basically, you need a time frame after which a new diagnosis is considered “delayed.” It should be a reasonable time interval after the patient has left the ED. If it’s too short an interval (e.g. once they leave the ED), your number will be unnecessarily high. If it’s too long (days and days later), then significant morbidity may occur that you don’t account for. Most centers have adopted 24, 36, or 48 hours after patient arrival.
Implement a tertiary survey process. This is a complete physical re-examination followed by a review of all diagnostic studies (lab and radiology) that have been performed. This exam needs to be dated and timed to ensure that it is performed within the time frame noted above. If a new finding is discovered on the tertiary survey, it is not considered a delayed diagnosis. If found after the survey (or after the pre-determined time interval), it is and must be entered into your performance improvement process.
Be paranoid. I hate the phrase, “maintain a high index of suspicion” because it’s meaningless. It’s like those stupid “start seeing motorcycles” bumper stickers. You can’t see what you can’t see. But you can be suspicious all the time, constantly looking for the inevitable clinical surprises of trauma care.

General

Does The Tertiary Survey Really Work?

November 25, 2022 The Trauma Pro Leave a comment

Delayed diagnoses / missed injuries are with us to stay. The typical trauma activation is a fast-paced process, with lots of things going on at once. Trauma professionals are very good about doing a thorough exam and selecting pertinent diagnostic tests to seek out the obvious and not so obvious injuries.

But we will always miss a few. The incidence varies from 1% to about 40%, depending on who your read. Most of the time, they are subtle and have little clinical impact. But some are not so subtle, and some of the rare ones can be life-threatening.

The trauma tertiary survey has been around for at least 30 years, and is executed a little differently everywhere you go. But the concept is the same. Do another exam and check all the diagnostic tests after 24 to 48 hours to make sure you are not missing the obvious.

Does it actually work? There have been a few studies over the years that have tried to find the answer. A paper was published that used meta-analysis to figure this out. The authors defined two types of missed injury:

Type I – an injury that was missed during the initial evaluation but was detected by the tertiary survey.
Type II – an injury missed by both the initial exam and the tertiary survey

Here are the factoids:

Only 10 observational studies were identified, and only 3 were suitable for meta-analysis
The average Type I missed injury rate was 4.3%. The number tended to be lower in large studies and higher in small studies.
Only 1 study looked at the Type II missed injury rate – 1.5%
Three studies looked at the change in missed injury rates before and after implementation of a tertiary survey process. Type I increased from 3% to 7%, and Type II decreased from 2.4% to 1.5%, both highly significant.
10% to 30% of missed injuries were significant enough to require operative management

Bottom line: In the complex dance of a trauma activation, injuries will be missed. The good news is that the tertiary survey does work at picking up many, but not all, of the “occult” injuries. And with proper attention to your patient, nearly all will be found by the time of discharge. Develop your process, adopt a form, and crush missed injuries!

Reference: The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med 20:77, 2012.

General

The Tertiary Survey for Trauma

November 22, 2022 The Trauma Pro Leave a comment

Major trauma victims are evaluated by a team to rapidly identify life and limb threatening injuries. This is accomplished during the primary and secondary surveys done in the ED. The ATLS course states that it is more important for the team to identify that the patient has a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration). However, once the patient is ready for admission to the trauma center, it is desirable to know all the diagnoses.

This is harder than it sounds. Physical examination tends to direct diagnostic testing, and some patients may not be feeling pain, or be awake enough to complain of it. Injuries that are painful enough may distract the patient’s attention away from other significant injuries. Overall, somewhere between 7-13% of patients have injuries that are missed during the initial evaluation.

A well-designed tertiary survey helps identify these occult injuries before they are truly “missed.” This survey consists of a structured and comprehensive re-examination that takes place within 48-72 hours, and includes a review of every diagnostic study performed. Ideally, it should be carried out by two people: one familiar with the patient, and the other not. It is desirable that the examiners have some experience with trauma (sorry, medical students).

The patients at highest risk for a missed injury are those with severe injuries (ISS>15) and/or impaired mental status (GCS<15). These patients are more likely to be unable to participate in their exam, so a few injuries may still go undetected despite a good exam.

I recommend that any patient who triggers a trauma team activation should receive a tertiary survey. Those who have an ISS>15 should also undergo the survey. Good documentation is essential, so an easy to use form should be used. Click here to get a copy of our original paper form. We have changed over to an electronic record, and have created a dot phrase template, which you can download here.

Next post: Does the tertiary survey actually work?

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