And here’s the last in my short “When To Call” series. This one’s a little different, and quite a bit longer. That’s due to the complexity and sheer number of potential orthopedic problems.
When consulting a specialty service, always keep the patient paramount in your decision making. Then think about how soon and under what context they really need to see the patient. Can it wait until morning? Do they even really need to be seen in the ED, or can this be an outpatient visit?
Tomorrow: Expectations on how your consultants should go about their business when seeing your patients.
Most trauma centers have a book of practice protocols or guidelines. Actually, it is required by the American College of Surgeons verification standards. All centers must have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes arises: why do we need another protocol? Why can’t I do it my own way?
I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols/guidelines.
In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.
- They allow us to build in adherence to any known literature support (evidence based).
- They help conserve resources by standardizing care orders and resource use. This means they save money!
- They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
- They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
- They promote team building, particularly when the protocol components involve several different services within the hospital.
- They teach a consistent, workable approach. This is especially important to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.
Tomorrow, I’ll write about imaging guidelines, and how they can help avoid VOMIT (victims of medical imaging technology).
Bottom line: It’s interesting that there are so many articles about practice guidelines, but very few explaining why they are important. Although the proof is not necessarily apparent in the literature, protocol and guideline development is important for trauma programs for the reasons outlined above. But don’t develop them just so you can have an encyclopedia of fifty! Identify common problems that can benefit from the consistency they provide. It will turn out to be a very positive exercise and reap the benefits listed above.
I still encounter a quite a bit of confusion about ED thoracotomy: when to do it, when to stop. A nice set of guidelines was developed by the Subcommittee on Outcomes of the American College of Surgeons Committee on Trauma about 10 years ago. And really, things haven’t changed very much since then.
In general, the literature on this topic has been all over the place. Most studies are retrospective with very little statistical validation. But there’s a lot of it out there. The subcommittee used fairly standard methods to evaluate the literature and come up with some recommendations.
The overall survival rate for all comers was 8% (11% for penetrating, 1.6% for blunt). About 15% of survivors (no breakdown of blunt vs penetrating) suffered from neurologic impairment. Penetrating cardiac injury had the best survival (31%). In the 4 studies on children, the survival numbers paralleled the adults.
Because of the relatively weak quality of the data, only level II recommendations were given. They were:
- Don’t consider ED thoracotomy in blunt trauma patients unless the patient arrests in front of you. Otherwise, meaningful survival is almost nonexistent.
- Consider ED thoracotomy for penetrating chest injury if there were witnessed signs of life and a short transport time (5-10 minutes max, in my opinion). Look for pupillary response, spontaneous respirations, palpable pulse, or a narrow complex cardiac rhythm.
- ED thoracotomy for penetrating abdominal injuries has a low survival rate, but can be considered if the injury may involve the chest.
- Consider thoracotomy for suspected abdominal vascular injury, but survival is also very low.
- The guidelines above apply equally to children.
Practical tips: ED thoracotomy is a seldom used and dangerous procedure. There are many opportunities for injury to trauma professionals, so be selective and take precautions. Assign someone to run the chemical code while the surgeons open the chest. Watch out for broken ribs and scalpels gone wild!
I’ll post pictures and specific pointers over the next three days.
Reference: Practice management guidelines for emergency department thoracotomy. JACS 193(3):303-309, 2001.