Category Archives: General

Jehovah’s Witnesses And Blood Transfusion Demystified

July 14, 2015 The Trauma Pro Leave a comment

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.

General

“Found Down”: Do We Need To Worry About The Abdomen?

July 8, 2015 The Trauma Pro Leave a comment

It’s that dreaded mechanism of injury: “found down.” What really happened? Did they fall, or get assaulted? Or did the patient suffer a medical problem that led to them falling down? Trauma professionals rely heavily on what I call “context.” Is the patient elderly and frail? Are they intoxicated? What was their location when found? Are there pre-existing medical conditions?

All of these factors allow us to begin building a story in our mind that tells us what might have happened, and what the injuries might be. But with little or no context, we are flying by the seat of our pants. We end up suspecting everything, which means we image everything. With CT scans. And IV contrast. There is always a chance that we can add to the harm already suffered by this patient, or waste time and money.

The abdomen is a black box in a patient with an unreliable or absent physical exam. The emergency medicine group at Cedars-Sinai in Los Angeles looked at the utlity of CT scanning the abdomen in this group of patients. They retrospectively reviewed 10 years of their data. They found 342 patients, of which 154 underwent some type of abdominal imaging (CT, FAST).

Here are the factoids:

About 60% had alcohol present, and 98% of those had a level greater than 0.08 g/dL
Overall mortality was 10%. 24 were trauma related (severe TBI, traumatic arrest in ED), and 9 were medical (CVA, sepsis)
55% did not undergo any abdominal imaging, and their mortality was 6% (TBI, stroke, MI). None manifested a late abdominal injury.
Of the 45% who did have abdominal imaging, 57% had CT, 24% FAST, and 19% both
14 patients in the imaged group had a positive abdominal CT, but all were minor (Abbreviated Injury Score (AIS) <3)
5 patients had a positive FAST, and all had an abdominal AIS<3

Bottom line: Patients who are “found down” seldom have significant intra-abdominal injuries. Keep in mind that this is a small study group, but it does seem to correlate with personal experience and reviews of many charts. Although you can’t completely ignore the abdomen in this group of patients, you should place a higher priority on head and neck trauma, or CVA/sepsis in patient without other obvious injury.

Related posts:

Reference: Abdominal injuries in the “found down”: is imaging indicated? J Am Col Surg 221(1):17-25, 2015.

General

Obit: Dr. John Hinds

July 7, 2015 The Trauma Pro Leave a comment

I just met John Hinds in person only two weeks ago. But that was enough to leave a lasting impression. He was charismatic, energetic, and dedicated to his craft. Witnessing him in action at SMACC Chicago, and watching his enthusiasm for emergency and trauma care was truly inspiring.

Unfortunately, John died on July 4th, doing what he loved. He was involved in an accident while providing medical cover for a practice session of the Skerries 100 motorcycle race in County Dublin.

The trauma world is now a little emptier, but John left a mark that will stay with us for a long time to come.

Related links:

General

To Probe or Not To Probe: Penetrating Wounds

July 7, 2015 The Trauma Pro Leave a comment

There is considerable variability in the way that penetrating wounds are approached. Some are located over areas of lesser importance (distal extremities) or are so superficial that they obviously don’t fully penetrate the skin.

Unfortunately, some involve high-value structures (much of the neck and torso), or are too small to tell if they penetrate (ice pick injury). How should these injuries be approached?

Too often, someone just probes the wound and makes a pronouncement based on that assessment. Unfortunately, there are major problems with this technique:

The tract may be too small to appreciate with a finger or even a cotton-tip swab
The tract may be oriented in an unexpected direction, or the soft tissues may have moved after the penetration occurred. In this case, the examiner may not appreciate any significant depth to the wound.
Inserting an object may violate a structure that you wish it hadn’t (resulting in a hissing sound after probing a chest wound, or a column of blood after probing the neck)

A better way to approach these wounds is as follows:

Is the patient unstable? If so, you know the penetration caused the problem and the patient belongs in the OR.
Is there other evidence of deep injury, such as peritonitis with a penetrating abdominal wound? If so, the patient still needs to go to the OR.
Do a legitimate local wound exploration. This entails making the hole bigger with a knife, and using surgical instruments and your eyes to find the bottom of the tract. Obviously, there are some parts of the body where this cannot be done, such as the face, but they probably don’t need this kind of workup anyway.

As one of my mentors, John Weigelt, used to say, “Doctor, do you have an eye on the end of your finger?” In general, don’t use anything that doesn’t involve an eyeball in your local wound explorations!

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