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!
And another law to end the first week! Any time I give a pediatric talk, I mention it. This one applies to anyone who takes care of children, and is particularly important to EMS / prehospital providers and emergency physicians.
On occasion, medics are called to a home to treat a child in extremis, or occasionally in arrest. Similarly, extremely sick children are often brought to the ED by parents or other caregivers.
Here’s the fifth law:
A previously healthy child who is in arrest, or nearly so, is a victim of child abuse until proven otherwise.
Bottom line: It’s so easy to go down the sepsis path with sick kids, especially those who can’t talk yet. But healthy children tend to stay healthy, and don’t easily get sick to the point of physiologic collapse. If you encounter one as a prehospital provider, glance around at the environment, and evaluate the caregivers. In the ED, ask pointed questions about the circumstances and do a full body examination. What you hear and what you see may drastically alter how you evaluate the patient and may save their life.
You’ve just received a young male who had been stabbed under his right arm in your emergency department. He’s awake, talking, and very friendly. He met your trauma activation criteria, so you are cruising through the full evaluation. Lines in, blood drawn, clothes off. He wonders aloud if all this is really necessary.
Then, on FAST exam, you see it. A pericardial stripe that looks like a mix of liquid and clotted blood. Your colleague steps in and verifies the exam. But vital signs are normal, the patient is fine.
What next? CT of the chest to further define this? A formal echo to confirm? Your surgeon says no, we’re going to the OR, now! Reluctantly, you package the patient and send him on his way. In the OR, the anesthesiologist takes his time, putting in an arterial line, asking the patient unrelated questions. A thoracotomy? Really? The patient remains awake and alert through all of this.
So here’s the fourth law of trauma:
Even awake, alert, and stable patients die. And it hurts that much more when they do.
Bottom line: You know the diagnosis in this case. And you know what needs to be done. But the awake and alert patient fools us. Fakes us out. Somehow, we equate the ability to talk intelligently with being fine. But evil things can be going on inside that don’t rear their ugly head until it’s too late. Don’t get suckered! Believe your exam, not what the patient thinks they are telling you.
Trauma patients don’t always behave the way we would like. They continually surprise us, sometimes for the better when they recover more quickly and completely than we thought. But sometimes it’s for the worse. They occasionally crash when we think everything is going so well.
The crashing patient is in obvious need of help and most trauma professionals know what to do. But then there’s the hypotensive patient. The BP just dropped to 84, and it’s not budging. Many don’t see this for what it is: a slow motion crash. And they want to do things they wouldn’t think of doing to a crashing patient. Like go to CT, do some more stuff in the ED because that BP cuff just has to be wrong, or call interventional radiology and wait for 45 minutes.
But here’s the sixth law of trauma:
The only place an unstable trauma patient can go is to the OR.
Bottom line: By definition, an unstable trauma patient is bleeding to death until proven otherwise (the second law, remember?). Radiation can’t fix that. Neither can playing around in the resuscitation room, unless the bleeding is spraying you in the face. The surgeon needs to quickly figure out which body cavity is the culprit, and address it immediately. And the only place with the proper tools to do that is an operating room.
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.