Category Archives: 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.

Philosophy

When Is It Too Late To Call A Trauma Activation?

July 6, 2017 The Trauma Pro Leave a comment

This is a related, follow-on post from yesterday, where I discussed activating your trauma team after transfer from another hospital. What about patients presenting directly to your hospital, but some time after their injury?

Admit it. It’s happened to you. You get paged to a trauma activation, hustle on down to the ED, and get dressed. The patient is calmly and comfortably lying on a cart, staring at you like you’re from Mars. Then you hear the story. He has a grade V spleen injury. But he just got back from CT scan. And his car crash was yesterday!

Is this appropriate? The answer is no! But, as you will see, the answer is not always as obvious as this example. The top thing to keep in mind in triggering a trauma activation appropriately is the reason behind having them in the first place.

The entire purpose of a trauma activation is speed. The assumption must be that your patient is dying and you have to (quickly) prove that they are not. It’s the null hypothesis of trauma.

Trauma teams are designed with certain common features:

A group of people with a common purpose
The ability to speed through the exam and bedside procedures via division of labor
Rapid access to diagnostic studies, like CT scan
Availability of blood products, if needed
Immediate access to an OR, if needed
Recognition in key departments throughout the hospital that a patient may need resources quickly

Every trauma center has trauma activation triage criteria that try to predict which patients will need this kind of speed. Does the patient in the example above need this? NO! He’s already been selected out to do well. Why, he’s practically finished the nonoperative solid organ management protocol on his own at home.

Here are some general rules:

If the patient meets any of your physiologic and/or anatomic criteria, they are or can be sick. Trigger immediately, regardless of how much time has passed.
If they meet only mechanism criteria and it’s been more than 6 hours since the event, they probably do not need the fast track.
If they only meet the “clinician / EMS judgment” criteria, think about what the suspected injuries are based on a quick history and brief exam. Once again, if more than 6 hours have passed and there are no physiologic disturbances, the time for needing a trauma activation is probably past.

If you do decide not to trigger an activation in one of these cases, please let your trauma administrative team (trauma medical director, trauma program manager) know as soon as possible. This may appear to be undertriage as they analyze the admission, and it’s important for them to know the reasoning behind your choice so they can accurately document under- and over-triage.

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