Category Archives: Philosophy

If A Tree Falls In A Forest…

October 20, 2017 The Trauma Pro Leave a comment

After yesterday’s analysis of a not-so-good pan-scan vs selective-scan abstract, it’s time for a little philosophy today. There seem to be two camps in the world of initial diagnostic testing for trauma: selective scanning vs scan everything. I admit that I am one of the former. Yes, the more tests you do, the more things you will find. Some will be red herrings. Some may be true positives, but are they important? Here’s the key question:

“If a tree falls in a forest and no one is around, does it make a sound?”

There is a clinical corollary to this question in the field of trauma:

“If an injury exists but no one diagnoses it, does it make a difference (if there would be no change in treatment)?”

Here’s an example. On occasion, my colleagues want to order diagnostic studies that won’t make any clinical difference, in my opinion. A prime example is getting a chest CT after a simple blunt assault. A plain chest xray is routine, and if injuries are seen or the physical exam points to certain diagnoses, appropriate interventions should be taken. But adding a chest CT does not help. Nothing more than the usual pain management, pulmonary toilet, and an occasional chest tube will be needed, and those can be determined without the CT.

Trauma professionals need to realize that we don’t need to know absolutely every diagnosis that a patient has. Ones that need no treatment are of academic interest only, and can lead to accidental injury if we look for them too hard (radiation exposure, contrast reaction, extravasation into soft tissues to name a few). This is how we get started on the path to “defensive medicine.”

Bottom line: Think hard about every test you order. Consider what you are looking for, what you might find, and if it will change your management in any way. If it could, go ahead. But always consider the benefits versus the potential risks, or what I call the “juice to squeeze ratio.”

References:

George Berkeley, A Treatise Concerning the Principles of Human Knowledge, 1734, section 45.
paraphrased by William Fossett, Natural States, 1754.

Philosophy

Why Is So Much Published Research So Bad?

September 28, 2017 The Trauma Pro Leave a comment

I read lots of trauma-related articles every week. And as I browse through them, I often find studies that leave me wondering how they ever got published. And this is not a new phenomenon. Look at any journal a year ago. Five years ago. Twenty years ago. And even older. The research landscape is littered with their carcasses.

And on a related note, sit down with any serious clinical question in your field you want to answer. Do a deep dive with one of the major search engines and try to get an answer. Or better yet, let the professionals from the Cochrane Library or other organization do it for you. Invariably, you will find hints and pieces of the answer you seek. But never the completely usable solution you desire.

Why is it so hard? Even with tens of thousands of articles being published every year?

Because there is no overarching plan! Individuals are forced to produce research as a condition of their employment. Or to assure career advancement. Or to get into medical school, or a “good” residency. And in the US, Level I trauma centers are required to publish at least 20 papers every three years to maintain their status. So there is tremendous pressure across all disciplines to publish something.

Unfortunately, that something is usually work that is easily conceived and quickly executed. A registry review, or some other type of retrospective study. They are easy to get approval for, take little time to complete and analyze, and have the potential to get published quickly.

But what this “publish or perish” mentality promotes is a random jumble of answers that we didn’t really need and can’t learn a thing from. There is no planning. There is no consideration of what questions we really need to answer. Just a random bunch of thoughts that are easy to get published but never get cited by anyone else.

Bottom line: How do we fix this? Not easily. Give every work a “quality score.” Instead of focusing on the quantity of publications, the “authorities” (tenure committees and the journal editors themselves) need to focus in on their quality. Extra credit should be given to multicenter trial involvement, prospective studies, and other higher quality projects. These will increase the quality score. The actual number of publications should not matter as much as how much high quality work is in progress. Judge the individual or center on their total quality score, not the absolute number of papers they produce. Sure, the sheer number of studies published will decline, but the quality will increase exponentially!

Philosophy

Why Is NPO The Default Diet For Trauma Patients?

September 25, 2017 The Trauma Pro Leave a comment

I’ve watched it happen for years. A trauma patient is admitted with a small subarachnoid hemorrhage in the evening. The residents put in all the “usual” orders and tuck them away for the night. I am the rounder the next day, and when I saunter into the patient’s room, this is what I find:

They were made NPO. And this isn’t just an issue for patients with a small head bleed. A grade II spleen. An orbital fracture. Cervical spine injury. The list goes on.

What do these injuries have to do with your GI tract?

Here are some pointers on writing the correct diet orders on your trauma patients:

Is there a plan to take them to the operating room within the next 8 hours or so? If not, let them eat. If you are not sure, contact the responsible service and ask. Once you have confirmed their OR status, write the appropriate order.
Have they just come out of the operating room from a laparotomy? Then yes, they will have an ileus and should be NPO.
Are they being admitted to the ICU? If their condition is tenuous enough that they need ICU level monitoring, then they actually do belong to that small group of patients that should be kept NPO.

But here’s the biggest offender. Most trauma professionals don’t think this one through, and reflexively write for the starvation diet.

Do they have a condition that will likely require an emergent operation in the very near future? This one is a judgment call. But how often have you seen a patient with subarachnoid hemorrhage have an emergent craniotomy? How often do low grade solid organ injuries fail if they’ve always had stable vital signs? Or even high grade injuries? The answer is, not often at all! So let them eat!

Bottom line: Unless your patient is known to be heading to the OR soon, or just had a laparotomy, the default trauma diet should be a regular diet!

Philosophy

The “Egg Timer” Injury

August 15, 2017 The Trauma Pro Leave a comment

Most patients with major traumatic injuries are handled in a very systematic way by both EMS and trauma centers. We have routines and protocols designed to provide rapid, quality care to these individuals. But over the years, I’ve begun to appreciate the fact that there is a very small subset of these patients who are different.

I term these patients as having an “egg timer injury”. These are patients who have only a certain number of minutes to live. This fact requires us to change the usual way we do things in order to save their lives or limbs. The usual routine may be too slow.

And unfortunately, no one can tell us exactly how many minutes are left on the timer. We only know that it’s ticking. Here are some examples of such injuries:

Pericardial tamponade

Penetrating injury to the torso with profound hypotension

Orbital compartment syndrome

In each case, speed is of the essence. What can we do to decrease the time to definitive intervention? For prehospital providers, you may need to bypass a closer hospital that might not have the necessary resources at a particular time of day. Once at the hospital, the patient may need to bypass the emergency department and proceed straight to the OR. Or you may need to do a lateral canthotomy yourself, rather than waiting for an ophthalmologist to drive in only to have the patient lose their vision because of the delay.

Bottom line: Remember that protocols are not necessarily etched in stone. They will cover 99.9% of cases you see. But that remaining 0.1%, the patients with the “egg timer injury”, will require you to think through what you know about the patient at the time, and make decisions about their care that may have a huge outcome on their life or livelihood. And as always, if you find that you must do things differently in the best interest of your patient, be sure to document what you knew and your thought processes thoroughly so you explain and/or justify your decision-making when you are invariably asked.

Philosophy, Resuscitation

Don’t Just Read The Abstract: CT Scanning The Unstable Patient

July 28, 2017 The Trauma Pro Leave a comment

I’ve said it many times before: “don’t just read the abstract.” They can be misleading, and doing so makes it impossible to see the shortcomings of the research model and the veracity of the conclusions. Yet good trauma professionals do it all the time.

So I’ve selected a recent poster child to demonstrate this tenet. Let’s go over the study details:

This paper is a retrospective, registry review from Japan. The authors point out that one of the long-held rules is to avoid scanning unstable trauma patients in the “tunnel of death.” The authors cite a prior study that did not show an increase in mortality from this practice. So they decided to repeat/confirm it using 11 years of national registry data.

They included all patients who arrived at the trauma center with blood pressure < 90. Interestingly, they excluded patients in frank or near arrest. And finally, patients with critical data points missing were excluded. They used a regression method to control for covariates such as age, ISS, and vitals upon arrival.

Here are the factoids:

Out of nearly 200,000 patients, about 7,000 were initially eligible. About 1,000 were excluded by the criteria above or because they were treated at a low volume facility. Only 5,809 were included in the study and another 500 were excluded because of missing covariates.
The authors found that there were significantly fewer deaths in the group of unstable patients taken to CT (20 fewer per 100 patients) (!!!?)
However, when corrected for confounders, this significant difference went away completely
But the authors conclusion in the abstract was: “We suggest physicians should consider CT as one of the diagnostic options even when patients are unstable.”

Bottom line: What? The study went from showing that taking an unstable patient to CT was amazing for decreasing mortality, to no different after applying more statistical methods. And since there was no difference, why not just go?

Here’s why. In-hospital and 24 hour mortality are not good indicators of anything because there are so many patient and hospital factors involved. And because it was a registry study, there was no way of knowing if the patient was hypotensive at the time they were taken to CT. They could have had a low blood pressure and responded well to resuscitation. Or they could have been normotensive on arrival and became hypotensive before CT scan. There is no way to cleanly identify the correct study group without a prospective study, or a very painstaking retrospective one.

One of the most important aspects of this study is some background info that is not stated in the paper. Surgeon involvement in initial resuscitation in Japan is not nearly as integrated as it is in the US. So if the resuscitating physicians can’t do anything about the bleeding in the ED, why not just scan them while awaiting arrival of the surgeon? If the patient crashes, was it due to the scan, or a delay in getting to the OR?

So don’t just read the abstract. If it seems to be too good to be true, it is. Or at least self-serving. Read the nitty gritty details and decide for yourself!

Next week: more on unstable patients and the CT scanner

Reference: Computed tomography during initial management and mortality among hemodynamically unstable blunt trauma patients: a nationwide retrospective cohort study. Scand J Trauma 25(1):74, 2017.

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