Category Archives: General

Mistaken Identity In Trauma Care

There was a well-publicized and tragic case of mistaken identity after a motor vehicle crash in Indiana about 8 years ago. A van carrying several college students and staff crashed, resulting in multiple fatalities at the scene. Survivors were transported to a Michigan trauma center, and it wasn’t until five weeks later that the identity mixup was discovered.

One of the fatally injured students and one of the survivors were both female, blonde, and about the same height and size. Their identities were not confirmed because the next of kin of the deceased was advised not to look at the body. And the face of the surviving woman was significantly contused and she had sustained multiple facial fractures. She remained comatose and intubated for over month after the other was buried (by the wrong family, it turns out). After extubation, she began correcting people who called her by the deceased woman’s name, and the correct identification was finally made.

How can this happen?! It’s not as difficult as it might seem, for a number of reasons:

  • Faces and identifying marks may be mutilated
  • Position in the vehicle may be mistaken
  • Bystander descriptions are notoriously inaccurate in these situations

It is neither practical nor safe to delay transport from the scene in the interest of obtaining positive identification. And hospitals have even less information than prehospital providers, whom they rely on almost exclusively for accurate data.

What can be done to avoid a case of mistaken identity? EMS and hospitals must develop protocols to follow in any case where multiple patients are treated at once. The baseline assumption must be that the identities are unclear or unknown until definitively made, and preferably from multiple sources. What are these definitive items?

  • An official ID that is still on the victim’s person (not cut off in the clothes)
  • Self identification
  • Visual identification from someone who personally knows the victim and views or talks to them
  • Written description, where the patients have very different identifying characteristics

However, remember that every one of these can be made in error. This is why multiple sources are so important. If in doubt, the patients should remain a “Doe” and not be given a real name.

If you have specific protocols or policies, please share them with me by email so I can post them!

Print Friendly, PDF & Email

How To: Retrograde Urethrogram

One of the hallmarks of urethral injury is blood and the meatus in males. The standard answer to the question “how do you evaluate for it?” is “retrograde urethrogram.” Unfortunately, too few people know how to perform this test, and not all radiologists are familiar. Many times it falls to the urologist, who may not be immediately available.

The technique is simple. The following items are needed:

  • A urine specimen cup
  • A tube of KY jelly (not the little unit dose packs)
  • A bottle of renografin or ultravist contrast
  • A 50-60 cc Toomey syringe (slip-tip)
  • A fluoroscopy suite

Pour 25cc of contrast and 25cc of KY jelly in the specimen cup, cap it and shake well. Draw the contrast jelly up into the syringe. Under fluoro, insert the tip of the syringe into the penis and pull the penis toward yourself, pinching the meatus around the tip of the syringe. Slowly inject all the contrast, watching the contrast column on the fluoro screen. Once there is easy flow into the bladder, you can stop the study. If you see extravasation into the soft tissues, stop the study and call Urology.

The advantages to using this technique are:

  • The contrast/jelly mix creates a contrast gel that is less likely to leak from the meatus when injected
  • The jelly makes it easy to insert the catheter if no urethral injury is detected

Normal urethrogram:

Normal urethrogram

Abnormal urethrogram:

Abnormal urethrogram

Print Friendly, PDF & Email

April Newsletter Released To Subscribers Thursday!

The April Trauma MedEd Newsletter will be released to subscribers this Thursday. The topic is Prehospital. Articles include:

  • Backboards
  • Aeromedical safety
  • Police transport
  • And more!

Anyone on the subscriber list as of 8PM Wednesday (CST) will receive it on May 1. I’ll release it to everyone else next Monday via the blog. So sign up for early delivery now by clicking here!

Pick up back issues here!

Print Friendly, PDF & Email

Again? Trauma Surgeon In-House vs At Home

Here we go again. Yet another paper debating whether we really need to have a trauma surgeon in-house at high level trauma centers. A paper published in December 2013 looks at this topic, and is a perfect illustration of why you need to read the whole article, not just the abstract!

This retrospective study primarily examined patient mortality, as well as a few other LOS indicators. They compared their results as they changed from having trauma surgeons who took call from home to taking in-house call. It involves only one trauma center in Lexington, Kentucky and covers two 21 month periods. 

Here are the factoids:

  • There were roughly 5000 patients each in the at-home and in-house groups
  • Overall demographics looked identical, even though the authors thought they detected differences in age and ISS
  • Time in ED, ICU LOS, hospital LOS decreased significantly, and percent taken to OR increased in the in-house group. There was no change in mortality.
  • These patterns were the same in trauma activation patients, who were obviously more seriously injured.
  • The authors conclude that having an in-house surgeon does not impact survival, but can speed things up for patients throughout their hospital stay.

I have many problems with this study:

  • The statistical results are weird. Many of the allegedly significant differences appear to be identical (e.g. mean age 44+/-19 vs 45+/-19, hospital LOS 3 days vs 3 days). And even if the authors found a test that makes them look statistically significant, they are clinically insignificant. ICU LOS differences were measured in hours, and 25 hours was significant? 
  • Attending presence “improved” from 51% to 88%. This means that they were not present in 1 of 5 trauma activations. This can easily overshadow any positive effect their presence may have had.
  • Mortality is too crude an indicator to judge the value of surgeon presence.
  • Lengths of stay can be due to so many other factors, it is not a valid measure either.
  • A retrospective, registry study has too few of the really critical data points

Bottom line: This paper is the poster child for why you MUST read the full paper, not just the abstract. If you had done the latter, you may believe that having an in-house surgeon is not necessary. Many papers (of variable quality) have looked at this (poorly) and there is no consensus yet. But it is a requirement for ACS verification if the surgeon can’t make it to the bedside of a seriously injured patients within 15 minutes. 

After observing trauma activations for 32 years, I know there is value in having an experienced surgeon present at the bedside during them. However, this value is very hard to quantify and every paper that has tried has not looked at the right variables. And these variables cannot be assessed in a retrospective, registry type study. 

Yes, there is no good, hard evidence of the value of the in-house surgeon. But it is there. Let’s stop publishing (and not critically reading) this kind of junk and confusing the issue!

Reference: Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency. J Am College Surg 281(4):734-738, 2013.

Print Friendly, PDF & Email

The Value of Protocols in Trauma

Most trauma centers have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question arose: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

Print Friendly, PDF & Email