Category Archives: Philosophy

Philosophy

When Is It Too Late To Call A Trauma Activation?

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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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Philosophy

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

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I had a great question sent in by a reader last week:

Some trauma centers receive a number of transfers  from referring hospitals. Much of the time, a portion of the workup has already been done by that hospital. 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. The reason you should be activating your team is that 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. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. 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. 

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Philosophy

Why Did The Trauma Team Cut Off My Clothes?

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The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting.

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.

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Philosophy

Pet Peeve: “High Index of Suspicion”

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How often have you heard this phrase in a talk or seen it in a print article:

“Maintain a high index of suspicion”

What does this mean??? It’s been popping up in papers and textbooks for at least the last 20 years. And to me, it’s meaningless. You try to figure out that sentence!

An index is a number, usually mathematically derived in some way. Yet whenever I see or hear this phrase, it doesn’t really apply to anything that is quantifiable. What the author is really referring to is “a high level of suspicion”, not an index.

This term has become a catch-all to caution the reader or listener to think about a (usually) less common diagnostic possibility. As trauma professionals, we are advised to do this about so many things, it really has become sad and meaningless.

Bottom line: Don’t use this phrase in your presentations or your writing. It’s stupid. And feel free to chide any of your colleagues who do. Give us some concrete tips so we don’t miss the diagnosis!

Reference: High index of suspicion. Ann Thoracic Surg 64:291-292, 1997.

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Philosophy

Best Of: VIP Syndrome In Healthcare (Very Important Person)

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The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.

Who is a VIP? It may be a celebrity. A family member. Or even a colleague. VIPs (or their healthcare providers) may have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.

Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.

Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.

How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to allproviders who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.

Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.

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