Category Archives: Philosophy

The Second Law Of Trauma

There are two broad categories of things that kill trauma patients. No, I’m not talking about violent penetrating injury, falls, car crashes, or any other specific mechanisms. I am referring to the end events (on a macro scale) that take their lives.

These two basic killers are: hemorrhage and brain injury. The vast majority of the time, a dying trauma patient has either suffered a catastrophic brain injury, or has ongoing and uncontrolled bleeding.

The Second Law Of Trauma

Your trauma patient is bleeding to death until you prove otherwise. 

Obviously, there are a few uncommon exceptions to this rule. This includes sources of obstructive shock such as tension pneumothorax and tamponade. But by and large, you will find this law a solid one.

Bottom line: Since there is little we can do above and beyond the basics in the ED for severe brain injury, your focus must be on hemorrhage. There are lots of things we can do about that, and the majority involve an operating room. Always assume that there is a source of hemorrhage somewhere, and it just hasn’t shown itself yet. There can be no rest until you prove that the source does not exist. And hopefully, you do that very, very quickly.

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The First Law Of Trauma

Let’s get started with the Laws of Trauma!

After pursuing any discipline for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.

The First Law of Trauma

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Some examples:

  • An elderly patient who crashes his car and presents with arrhythmia and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab. It is far more likely the crash is causing these problems rather than an MI causing a crash.
  • A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
  • A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.
  • A patient who follows up in your trauma clinic with new complaints after a previous gunshot to the abdomen needs further clinical investigation, not just reassurance.

Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Injury can and does kill people more quickly that an MI or a stroke, especially if it was never suspected.

Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.

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The Laws Of Trauma

It’s been five years since I published my Laws of Trauma, and it’s time to dust them off again. In the meantime, I’ve added a couple of new ones.

But before I start publishing them next week, I’d like to take a moment to share “McSwain’s Rules of Patient Care.”  I met Norm McSwain when I was junior faculty at the University of Pennsylvania. As so many of his era were, he was larger than life. He was friendly, outgoing, animated, and a real champion for quality trauma care.

Norm was a skilled surgeon and teacher, but his achievements were felt far outside his home in Louisiana. He was an early member of the ACS Committee on Trauma, and was very involved in the development of the Advanced Trauma Life Support and Prehospital Trauma Life Support courses. He is credited with developing the original EMS programs in both Kansas, where he took his first faculty position out or residency, and in New Orleans, his home for the remainder of his life. He spent his career at the Charity Hospital there, weathering multiple political storms over the years, as well as the big one, Hurricane Katrina. He was instrumental in achieving Level I Trauma Center status for its replacement, Interim LSU Hospital.

Norm’s accomplishments are, as many of his contemporaries who have left us, too numerous to count. I certainly won’t try to recount them here. But it was his charm, his love for his charges, and his willingness to teach every trauma professional that will always be remembered.

I’ll leave you with his 18 rules of patient care. They are timeless, and will serve you well regardless of your degree and level of medical training.

Download McSwains Rules of Patient Care

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Yet Another One: The Eleventh Law Of Trauma

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 of 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 publications that are of lower quality.

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”

And here is it’s corollary:

“Don’t believe everything you think!”

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

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Coronavirus (COVID-19) And Your Trauma Service

In my last post, I made some suggestions on how to modify the trauma activation process to better protect your team members from exposure to the Coronavirus. Today, I’ll discuss some things you can do to reduce the exposure of your in-house team that provides care for patients.

First off, I’m not going to discuss the obvious things like personal protective equipment, or what to do when performing risky procedures such as intubation or extubation. Those have been covered elsewhere and each hospital has adopted its own standards.

I will be discussing more general concepts that help limit team member exposure to possible contamination or infected individuals. Here are some of my suggestions:

  • Make sure your hospital conserves the resources it needs to be a trauma center. A certain number of ICUs, operating rooms, and floor beds must be reserved for trauma patients. Your hospital should make contingency plans such that if COVID-19 patients are getting close to taking too many beds or other resources, there is an escape valve so they can be diverted or transferred to other non-trauma hospitals.
  • Save your trauma surgeons for things only they can do. Many hospitals have general surgeons on staff in addition to their trauma/critical care surgeons. Remove the trauma surgeons from emergency general surgery / acute care surgery services and concentrate them on the trauma and critical care services. Have the general surgeons cover the other services, and send all idle trauma surgeons home where it is safer. Rotate them through trauma and critical care on a regular basis. Imagine what would happen if you lose 2 or 3 of your trauma surgeons at the same time, and don’t let it happen to you!
  • Eliminate non-essential meetings and conferences. This includes morbidity and mortality conferences, journal clubs, and all educational conferences. These things have to go on the back burner for now and can be re-instituted once things return to normal.
  • Practice social distancing at essential meetings. Certain gatherings are unavoidable, such as care handoffs (“morning report,” and “afternoon check-out”). Reduce the attendees to only those whose input is critical. If needed, they can gather information from other small groups of providers to prepare for the essential meeting. But no more crowded rooms, please.
  • Don’t congregate with other providers unnecessarily. This means outside your office, in the lounge, and in the lunchroom. The usual social norms need to take a back burner to your own safety and health.
  • Use telephone conferencing as much as possible. You will be surprised at how many of these less-than-essential meetings can be handled virtually, or eliminated. One tip, though: print a copy of the agenda for reference. It seems to be more difficult to follow the flow of the meeting (and take/make notes) if you don’t have something you can visually refer to.
  • Redesign your care team. Do you really need your entire team (APPs, residents, nurses) hanging around all day like they usually do? The reality is that the bulk of the work on any trauma service generally takes place in the morning. The rest of the day is spent waiting for incoming trauma patients. Calculate the optimal number of providers based on your service census. Do the morning work, go on rounds (smaller groups, please), finish any post-rounds chores, then send the extras home. And rotate those providers so that some can spend time at home while the others are in-house.
  • Use residents wisely if you have them. They are part of your care team, too, so be sure to minimize their exposure. The previous tip on redesigning the care team applies to them, too. And frequently, they rotate through several hospitals, many of which are not doing elective surgery. So they may not have a lot to do. Work with the residency program director to see if you can temporarily add them to the trauma center coverage pool. This allows you to keep a larger number of residents at home while maintaining a reasonable number for your care team.

In my next post, I’ll cover changes you should consider in your Massive Transfusion Protocol.

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