Category Archives: Guidelines

Practice Guidelines And Tincture Of Time

Most trauma centers have at least a few practice guidelines to help the standardize the way they manage common injuries. Solid organ injury. Elder trauma. Chest tube management. But they are all designed for use in patients who present shortly after their injury.

What about someone who presents a day or two, or more, after their injury?  That changes the picture entirely. Most guidelines have a time component built in. A TBI protocol requires a repeat head CT after a certain period of time. Solid organ injury patients may have restricted activity or frequent vital signs for a while.

But all too often, trauma professionals treat the patient with delayed presentation exactly the same as fresh trauma. For example, a patient falls and bumps their head. They have a persistent headache, and after two days decide to visit their local ED. The CT scan shows a small amount of subarachnoid blood in the area of the impact. Your practice guidelines says to admit for observation, frequent neruo checks, and repeat head CT in 12 hours.

Or a young male playing sports took a hit to his left flank. After 3 days, he’s just tired of the pain and comes to the ED for some pain medication. CT scan shows a grade III spleen injury with a small amount of hemoperitoneum. Your protocol says to admit, make NPO, liimit activity, and observe for 2 days.

What would I do in these cases? Think about it! If the patients had presented right after the event, they would have gone through your guideline and would have been discharged already. So I would review the images, talk to the patients about their injuries, then send them home from the ED with followup. They’ve already passed!

Bottom line: Remember, practice guidelines are not etched in stone. Variances are possible, but need to be well thought out in advance. And hopefully documented in the chart to expedite the inevitable trauma performance improvement inquiry. If the requisite amount of time has gone by, and the history and exam are reasonable, the patient has already passed your protocol. Send them home.

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When To Call: Ophthalmology

Here’s another in my series of “When To Call” pieces. We sometimes overuse our consultants and call then at inappropriate times. So what if we diagnose an injury in their area of expertise at 2 am? Does it need attention or an operation before morning? If not, why call at that ungodly hour?

Let’s use our consultants wisely! I’ve listed most of the common eye diagnoses that trauma professionals will encounter. There is also an indication of what you need to do, and exactly when to call your consultant.

Unfortunately, this one won’t fit on a 3×5 index card that you can keep in your pocket. I’ve included a printable pdf file, as well as the original Microsoft Word file in case you want to make a few modifications to suit your own hospital.

Enjoy!

When to call Ophthalmology reference card (pdf)

When to call Ophthalmology MS Wordfile (docx)

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When To Call: Urology

Here’s one in a series of “When To Call” pieces. We sometimes overuse our consultants and call then at inappropriate times. So what if we diagnose an injury in their area of expertise at 2 am? Does it need attention or an operation before morning? If not, why call at that ungodly hour?

Let’s use our consultants wisely! I’ve listed most of the common urologic diagnoses that trauma professionals will encounter. There is also an indication of what you need to do, and exactly when to call your consultant.

Here’s a reference sheet formatted at a 3×5 index card that you can keep in your pocket. I’ve included a printable pdf file, as well as the original Microsoft Publisher file in case you want to make a few modifications to suit your own hospital.

Enjoy!

When to call Urology reference card (pdf)

When to call Urology MS Publisher file (pub)

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Why Can’t I Do Things The Way I Want?

Most trauma centers have a book of practice protocols or guidelines. Actually, it is required by the American College of Surgeons verification standards. All centers must have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes arises: why do we need another protocol? Why can’t I do it my own way?

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/guidelines.

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 literature support (evidence based).
  • They help conserve resources by standardizing care orders and resource use. This means they save money!
  • 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. This is especially important to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

Tomorrow, I’ll write about imaging guidelines, and how they can help avoid VOMIT (victims of medical imaging technology).

Bottom line: It’s interesting that there are so many articles about practice guidelines, but very few explaining why they are important. Although the proof is not necessarily apparent in the literature, protocol and guideline development is important for trauma programs for the reasons outlined above. But don’t develop them just so you can have an encyclopedia of fifty! Identify common problems that can benefit from the consistency they provide. It will turn out to be a very positive exercise and reap the benefits listed above.

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A New Proposed Practice Guideline For Cervical Spine Clearance

In my last post, I reviewed a very recent prospective study on using CT scan alone for  cervical spine clearance in intoxicated patients. I believe that this is the final piece in the spine clearance puzzle to allow us to perform this task intelligently.

We’ve been accumulating more and more data that supports the use of CT scan in patients who fail clinical clearance. This failure can be due to the patient being obtunded or intoxicated, bearing a “distracting” injury, or being just plain uncooperative. Because of this, and our fear of missing a potentially devastating injury (typically because of rare anecdotal cases or urban legends), we have resorted to a significant degree of overkill. This has included, over the years, prolonged immobilization in a rigid collar, flexion/extension imaging (plain x-ray or fluoro), and MRI.

I’ve synthesized the available literature, and have drafted a simple, one sheet practice guideline for discussion. In order to use it, you must have the following:

  • A decent CT scanner – minimum 64 slice
  • A well-defined scan setup protocol – 3mm collimation, skull base to T2, 2-D reconstruction in sagittal and coronal planes (get a copy of our protocol below)
  • A skilled radiologist – neuroradiologist required

An image of the protocol can be found at the bottom of this post. I’m interested in your comments, and your comfort or discomfort with adopting something like this. Please leave comments here or on twitter.

Links: 

Reference: Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey. J Trauma 83(6):1032-1040, 2017.

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