Category Archives: General

Orthopedic Hardware And TSA Metal Detectors

Many trauma patients require implantable hardware for treatment of their orthopedic injuries. One of the concerns they frequently raise is whether this will cause a problem at TSA airport screening checkpoints (Transportation Safety Administration).

The answer is probably “yes.” About half of implants will trigger the metal detectors, and these days that usually means a pat down search. And letters from the doctor don’t help. It turns out that overall, 38% are detected when the scanner is set to low sensitivity and 52% at high sensitivity.

Here is a more detailed breakdown:

  • Lower extremity hardware is detected 10 times more often than upper extremity or spine implants
  • 90% of total knee and total hip replacements are detected
  • Upper extremity implants such as shoulder, wrist and radial head replacements are rarely detected
  • Plates, screws, IM nails, and wires usually escape detection
  • Cobalt-chromium and titanium implants trigger alarms more often than stainless steel

If your patient knows that their implant triggers the detectors, they have two options: request a patdown search, or volunteer to go through the full body millimeter wave scanner. This device looks at everything from the skin outwards, and will not “see” the implant and is probably the preferred choice. If they choose to go through the metal detector and trigger it, they are required to have a patdown. Choosing to go through the body scanner after setting off the detector is no longer an allowed option.

Reference: Detection of orthopaedic implants in vivo by enhanced-sensitivity, walk-through metal detectors. J Bone Joint Surg Am. 2007 Apr;89(4):742-6.

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The Fourth Law Of Trauma

And now, the last one in the series (for now).

You’ve just received a young male who had been stabbed under his right arm in your emergency department. He’s awake, talking, and very friendly. He met your trauma activation criteria, so you are cruising through the full evaluation. Lines in, blood drawn, clothes off. He wonders aloud if all this is really necessary.

Then, on FAST exam, you see it. A pericardial stripe that looks like a mix of liquid and clotted blood. Your colleague steps in and verifies the exam. But vital signs are normal, the patient is fine.

What next? CT of the chest to further define this? A formal echo to confirm? Your surgeon says no, we’re going to the OR, now! Reluctantly, you package the patient and send him on his way. In the OR, the anesthesiologist takes his time, putting in an arterial line, asking the patient unrelated questions. A thoracotomy? Really? The patient remains awake and alert through all of this.

So here’s the fourth law:

Even awake, alert, and stable patients die. And it hurts that much more when they do.

Bottom line: You know the diagnosis in this case. And you know what needs to be done. But the awake and alert patient fools us. Fakes us out. Somehow, we equate the ability to talk intelligently with being fine. But evil things can be going on inside that don’t rear their ugly head until it’s too late. Don’t get suckered! Believe your exam, not what the patient thinks they are telling you.

Other Laws of Trauma:

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The Third Law Of Trauma

Trauma patients don’t always behave the way we would like. They continually surprise us, sometimes for the better when they recover more quickly and completely than we thought. But sometimes it’s for the worse. They occasionally crash when we think everything is going so well.

The crashing patient is in obvious need of help and most trauma professionals know what to do. But then there’s the hypotensive patient. The BP just dropped to 84, and it’s not budging. Many don’t see this for what it is: a slow motion crash. And they want to do things they wouldn’t think of doing to a crashing patient. Like go to CT, do some more stuff in the ED because that BP cuff just has to be wrong, or call interventional radiology and wait for 45 minutes.

But here’s the thing:

The only place an unstable trauma patient can go is to the OR.

Bottom line: By definition, an unstable trauma patient is bleeding to death until proven otherwise (the second law, remember?). Radiation can’t fix that. Neither can playing around in the resuscitation room, unless the bleeding is spraying you in the face. The surgeon needs to quickly figure out which body cavity is the culprit, and address it immediately. And the only place with the proper tools to do that is an operating room.

Other Laws of Trauma:

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The Second Law Of Trauma

There are two broad categories of things that kill trauma patients. No, I’m not talking about violent penetrating injury, falls, car crashes, or any other specific mechanisms. I am referring to the end events (on a macro scale) that take their lives.

These two basic killers are: hemorrhage and brain injury. The vast majority of the time, a dying trauma patient has either suffered a catastrophic brain injury, or has ongoing and uncontrolled bleeding.

Here’s the law:

Your trauma patient is bleeding to death until you prove otherwise. 

Bottom line: Since there is little we can do above and beyond the basics in the ED for severe brain injury, your focus must be on hemorrhage. There are lots of things we can do about that, and the majority involve an operating room. Always assume that there is a source of hemorrhage somewhere, and it just hasn’t shown itself yet. There can be no rest until you prove that the source does not exist. And hopefully, you do that very, very quickly.

Other Laws of Trauma:

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The First Law Of Trauma

Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.

The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Some examples:

  • An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
  • A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
  • A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.

Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.

Other Laws of Trauma:

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