Category Archives: Tips

Mistaken Identity In Trauma Care

There was a well-publicized and tragic case of mistaken identity after a motor vehicle crash in Indiana a number of years ago. A van carrying several college students and staff crashed, resulting in multiple fatalities at the scene. Survivors were transported to a Michigan trauma center, and it wasn’t until five weeks later that the identity mixup was discovered.

One of the fatally injured students and one of the survivors were both female, blonde, and about the same height and size. Their identities were not confirmed because the next of kin of the deceased was advised not to look at the body. And the face of the surviving woman was significantly contused and she had sustained multiple facial fractures. She remained comatose and intubated for over month after the other was buried (by the wrong family, it turns out). After extubation, she began correcting people who called her by the deceased woman’s name, and the correct identification was finally made.

How can this happen?! It’s not as difficult as it might seem, for a number of reasons:

  • Faces and identifying marks may be mutilated
  • Position in the vehicle may be mistaken
  • Bystander descriptions are notoriously inaccurate in these situations

It is neither practical nor safe to delay transport from the scene in the interest of obtaining positive identification. And hospitals have even less information than prehospital providers, whom they rely on almost exclusively for accurate data.

What can be done to avoid a case of mistaken identity? EMS and hospitals must develop protocols to follow in any case where multiple patients are treated at once. The baseline assumption must be that the identities are unclear or unknown until definitively made, and preferably from multiple sources. What are these definitive items?

  • An official ID that is still on the victim’s person (not cut off in the clothes)
  • Self identification
  • Visual identification from someone who personally knows the victim and views or talks to them
  • Written description, where the patients have very different identifying characteristics

However, remember that every one of these can be made in error. This is why multiple sources are so important. If in doubt, the patients should remain a “Doe” and not be given a real name.

If you have specific protocols or policies, please share them with me by email so I can post them!

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Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.

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Next Week: The Electronic Trauma Flow Sheet

It’s been a while since I visited the topic of the electronic trauma flow sheet (eTFS) for trauma activations. A few years have passed, the software engineers have gotten smarter (hopefully), so let’s look at it again.

Next week, I’ll be covering the eTFS in detail again. Here is what I will touch on:

  • eTFS: Why Hospitals Want To Switch
  • What Does(n’t) Work
  • Oops! Now What Are My Options?

I’d also like to spend a day on Q&A. To that end, please start emailing, commenting, or tweeting your questions so I can answer them in detail at the end of the week. Let the games begin!

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Best Of: Finding Rib Fractures On Chest X-Ray

A lot of people have been viewing and requesting this post recently.

Here’s a neat trick for finding hard to see rib fractures on standard chest xrays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail xrays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest xray. So tip the xray on its side and make those curves into nice arches, then let your eyes follow them naturally:

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. 

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