The invention of video-assisted laryngoscopy and intubation has been a huge boon to trauma professionals. So it irks me to no end when I see them misusing the technology.
I call this phenomenon non-video laryngoscopy and intubation. Take a look at this picture:
What’s wrong, you say? Who’s watching the #@*! video screen??!
This intubator is basically using a clunky, old-fashioned laryngoscope tethered by two huge cables. Which makes it worse than a clunky, old-fashioned laryngoscope.
Bottom line: Your hospital has provided an expensive piece of equipment to help you intubate better and more reliably. You no longer have to peer down a narrow channel in the oropharynx, while blocking your own view with the ET tube.
A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:
Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.
In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.
Here are some tips for each of the areas:
Penis – Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
Scrotum – Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
Vagina – external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
Perineum – Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
Anus – Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
Natal cleft – Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position.
Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.
Here’s another one. I’ve seen the clinical problems and poor outcomes that can arise from ignoring it many times over the years.
You’ve ordered a CT or a conventional x-ray image. The result comes back in your EMR. You take a quick glance at the summary at the bottom of the report. No abnormal findings are listed. So now, in your own mind and in any sign-outs that you provide, the image is normal.
Here’s the rub. Saying something is not abnormal doesn’t necessarily mean that it’s normal. Hence the sixth law:
Always look at the image yourself.
Sometimes, the radiologist misses key findings on the image. Sometimes they see them and make a note of them in the body of the report. But they don’t get the clinical significance and don’t mention it in the summary (which is the only thing you looked at, remember?).
Bottom line: Always make a point to pull up the actual images and take a look. You have the full clinical picture, so you may appreciate findings that the radiologist may not. Sure, you may not have much experience or skill reading more sophisticated studies, but how do you think you develop that? Read it yourself!