Category Archives: Philosophy

Don’t Write This In Your PI Committee Minutes!

One of the more poorly understood concepts in trauma performance improvement is the focus of the process. Are we really discussing the patient who had a quality issue?

I occasionally see something like the following in the published multidisciplinary trauma PI committee minutes:

“Although an opportunity for improvement was found, it was non-contributory and had no impact on patient outcome.”

Unfortunately, the true purpose of the committee discussion has been lost. The simple truth is that we are trying to learn from a patient we have cared for. None of the events or opportunities for improvement identified can impact them. Time has passed, and if there were any irregularities in their care, it is too late to fix them. For this patient.

However, the proper focus of the performance improvement program is to make things better for the next, similar patient. Here’s an example:

Scenario 1: An elderly patient presents after a fall with a mild head strike. They are awake and alert and present to a trauma center where this is recognized as a high-risk mechanism. A limited activation occurs, the patient is rapidly assessed, and she is whisked off to CT scan 20 minutes after arrival. The report is back in 10 minutes and shows a 1.5cm subdural hematoma with mild ventricular effacement.

Neurosurgery is rapidly consulted and sees the patient within 15 minutes. He plans an emergent operation. The patient is taken to the OR two hours later for a successful craniectomy and drainage. She does well and is discharged home neurologically intact four days later.

Everything looks great, right? Unfortunately, no.

This case could very easily be called a great save. But the patient’s identical twin sister comes in two weeks later with exactly the same presentation. What if the patient vomits, becomes unresponsive, and blows her pupils just one hour after the neurosurgeon sees her? They get a stat repeat CT, and the neurosurgeon now pronounces the larger lesion a non-survivable injury.

The second case will definitely end up being discussed by your multidisciplinary trauma PI committee as a death. Perhaps the one-hour delay is deemed acceptable because “that’s how we do it here” (shudder, a big red flag).

But what if the PI process picks up that two-hour delay in the first case and deems it suboptimal despite the rosy outcome? Processes are implemented to get an OR ready quicker and ensure the neurosurgeon’s availability. Now, a patient can theoretically be in the OR within 30 minutes of this “emergency” designation. When the second patient arrives two weeks later, this new process works flawlessly, and she, too, has a great outcome.

Bottom line: Your PI program is designed to protect the next similar trauma patient arriving at your center. Don’t forget that. Scrutinize care closely, even if the outcome was great and it’s exactly how you “normally” do it. Ask yourself if you would be satisfied if it were your spouse, parent, or child receiving that care. If not, fix everything that isn’t right. For all you know, that next patient could very well be your family member!

Do I Have To Call My Trauma Team For Incoming Transfers?

Some trauma centers receive a significant number of transfers from referring hospitals. Much of the time, the outside hospital has already done a portion of the workup. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. You should be activating your team because you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

  • Physiologic. You must activate if there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma). Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
  • Anatomic. Most simple anatomic criteria (e.g., long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
  • Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
  • Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team. 

And finally, if the patient meets any of the ACS hard criteria for activation (this includes hypotension, transfusing blood, and respiratory compromise), don’t hesitate to trigger the activation!

The Eleventh Law Of Trauma

Here’s the last one… for now.

If you have followed this blog for any period of time, you are aware of the skepticism I bring to bear when I am reading new material or learning about new ideas. Why is this? Because it is very difficult in this day and age to ascertain the veracity of anything we see, hear, or read.

This is not new compared to, say, a hundred years ago. The media were a bit different, but the underlying issues were the same. There have always been two major factors at play: information overload and the biases built into our human brain operating system.

There is a huge body of new information in every field that is being produced every year. Given the pressures that most researchers are under to publish or perish, a huge number of papers are sent to journals for review. Unfortunately, this leads to a huge number of lower-quality publications.

This also contributes to another recognized phenomenon, the half-life of facts. Think about all the things you learned during your training that are no longer believed to be true. Stress causes ulcers. Steroids are good in head injury. There is a definite decay curve for the old facts that occurs as new knowledge is acquired.

So we have a huge amount of potential junk to sort through to figure out what cellular mechanisms are correct or which medications work for a disease. And then we run into our own operating system problems.

All humans have our own innate beliefs that are shaped by experience and all the information we’ve consumed over the years. And we are genetically programmed to do this:
Learn something new  —>  believe it  —>  verify it

And many of us never get to the verify stage because another operating system issue, confirmation bias, takes over. If we learn something that confirms an existing belief, we are much more likely to believe and much less likely to verify. If we learn something that opposes our belief, we still want to believe what we already do and find every flaw in the new data that might refute it.

So here is my eleventh law of trauma:

“Don’t believe anything you learn, especially if it supports what you already believe”

Bottom line: If you read or hear something new, first examine the source. Is it legitimate and reliable? Where did it get the info? Then check out that source. Critically evaluate it, even if it already supports what you believe. Always treat new information, especially if you think it’s right, as an opportunity to learn something new. Sometimes you will find real gems in the things you thought were wrong, and real crap in the things you believed to be right!

It’s time to flip the algorithm to:
Learn something new  —>  verify it  —>  believe it

The Tenth Law Of Trauma

Several years ago, I ran a series of posts on my Laws of Trauma. I assembled them into  newsletter that contained all nine that existed at the time. If you’d like to download it, just click this link.

I’ve  been struck by another pattern, and I think it’s about time to add the tenth law. Weirdly enough, it was inspired by Dancing With The Stars. You’ll see what I mean.

Here is the Tenth Law of Trauma:

In trauma, it generally takes two to tango

So what does this mean? When dealing with injury, there are a few broad quantitative categories.

  • Single person mechanism. This is one extreme. Common examples would be the elderly fall, a single vehicle car crash, or a self-inflicted stab or gunshot. There is a single “point of failure” that only the individual involved can manage, but for various reasons they do not or cannot. This law does not apply.
  • Multiple person mechanism. This is the other extreme, and thankfully is not seen very often at all. Examples are a tour bus crash, house explosion, or mass casualty event. Once again, those involved usually have little ability to recognize or avoid the imminent event, and the tenth law is null and void.
  • Two person mechanism. This one is very common, and is exemplified by the two car crash, pedestrian struck, or the various flavors of assault. And this is the one that the tenth law applies to.

When two people are involved in an event that leads to traumatic injury, there is usually (but certainly not always) a set of checks and balances that is present. And frequently there is at least one opportunity to avoid the event.

In the case of a two vehicle crash, one driver may have “gone off the deep end” and ignored the usual traffic laws for whatever reason. But the second driver usually has an opportunity to recognize this and change their behavior in order to avoid the situation. However, if they are distracted, impaired, or making assumptions about how other driver behave they can still get into trouble. Thus, it takes two.

What about the pedestrian struck? Likewise, the driver or the pedestrian may have done something nonstandard. Wear dark clothes at night. Glance at their phone while driving. Look at their passenger a bit too long while having a conversation. Once again, the other participant may have an opportunity to see the result of this unexpected behavior and jump or swerve out of the way.

Interpersonal violence it a bit more tricky. Sure, one of the potential participants may get wind that something is up and try to avoid or defuse the situation. But not always. And this situation is heavily charged with emotion and social pressures and is much more difficult to change or avoid.

Bottom line: Many, but certainly not all,  “two-person” mechanisms of injury are avoidable if both of the individuals involved are mentally present and attentive to their surroundings. Look at your own patient population and see how often this applies. You may be surprised!

Ninth Law Of Trauma

Okay, here’s another one! But it’s a doozy. It’s the most important one I live by. It ensures that you don’t get bogged down by habit, custom, dogma, ignorance, or just plain laziness.

Question everything!

If someone ever says, “but that’s the way I/we always do it,” or “that’s what the policy says,” or even “I read a good paper/chapter on this,” take it with a really big grain of salt. Or a salt lick (if you know what that is; otherwise look it up).

And here’s a corollary:

Don’t believe everything you think!

Consider that one for a minute.

Bottom line: It’s up to you to decide what is right for your patients. Others may not have done the leg-work and may not be as knowledgeable as you think. Always check the facts!