Tag Archives: pet peeve

Pet Peeve

Pet Peeve: “High Index of Suspicion”

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How often have you heard this phrase in a talk or seen it in a journal article:

“Maintain a high index of suspicion”

What does this mean??? It’s been popping up in papers and textbooks for at least 30 years. And to me, it’s meaningless. You try to figure out that sentence!

An index is a number, usually mathematically derived in some way. Yet whenever I see or hear this phrase, it doesn’t apply to anything quantifiable. What the author is really referring to is “a high level of suspicion,” not an index.

This term has become a catch-all to caution the reader or listener to think about a (usually) less common diagnostic possibility. As trauma professionals, we are advised to do this about so many things, it really has become sad and meaningless. And don’t we all do this anyway?

Bottom line: Don’t use this phrase in your presentations or writing. It’s silly and doesn’t make any sense. And feel free to chide any of your colleagues who do. Please give us some concrete data so we don’t have to be so suspicious!

Reference: High index of suspicion. Ann Thoracic Surg 64:291-292, 1997.

Technique

The Trauma Activation Pat-Down?

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Yes, this is another one of my pet peeves. During a trauma activation, we all strive to adhere to the Advanced Trauma Life Support protocols. Primary survey, secondary survey, etc. Usually, the primary survey is done well.

But then we get to the secondary survey, and things get sloppy.

police_frisk1

The secondary survey is supposed to be a quick yet thorough physical exam, both front and back. But all too often it’s quick, and not so thorough. There is the usual laying on of the hands, but barely. Abdominal palpation is usually done well. But little effort is put into checking stability of the pelvis. The extremities are gently patted down with the hope of finding fractures. Joints are slightly flexed, but not stressed at all.

Is it just a slow degradation of physical exam skills? Is it increasing (and misguided) faith in the utility of the CT scanner? I don’t really know. But it’s real!

Bottom line: Watch yourself and your team as they perform the secondary survey! Your goal is to find all the injuries you can before you go to imaging. This means deep palpation, twisting and trying to bend extremities looking for fractures, stressing joints looking for laxity. And doing a good neuro exam! Don’t let your physical exam skills atrophy! Your patients will thank you.

Imaging

Wear The Damn Lead Gown!

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Pet peeve time. All trauma team members must wear personal protective equipment (PPE) when they attend a trauma activation. It’s for their own protection as well as our patients’. When I am the primary faculty at any trauma activation, I quickly scan all the other team members to ensure they are wearing it. If not, I give them a “gentle reminder” that they need to go get dressed properly.

This is all well and good. But recently I’ve noticed a trend when it comes time to shoot the basic x-rays needed for assessment (chest and/or pelvic images). When the radiology tech calls out to clear the torso and make sure someone else’s head or hands are not over the patient, half the team goes running out of the room. They are missing one key component of their gear:

Yes, their lead gown! Now granted, the amount of radiation exposure is not huge as I’ve documented in previous posts. But it is cumulative and for safety reasons, x-ray exposure must be limited.

But is running out of room the best way to decrease exposure? I think not! This is very disruptive to the way the team should function and interrupts patient care. Ideally, everyone in the room within 2-3 meters of the x-ray tube should be shielded in some way. And the most effective way to do this is to wear the damn lead gown!

Bottom line: I’ve adjusted my scan when the trauma team assembles. I now look for a lead gown underneath the usual PPEs. And if I don’t see it, I remind the offenders that, if they leave the room when the x-rays are taken, I’m not letting them back in. It’s been very effective at reversing this troubling trend.

In my next two posts, I’ll detail how much radiation the team is exposed to, and how much our patients receive from the studies we order.

Technique

The Trauma Activation Pat-Down?

Leave a comment

Yes, this is another one of my pet peeves. During a trauma activation, we all strive to adhere to the Advanced Trauma Life Support protocols. Primary survey, secondary survey, etc. Usually, the primary survey is done well.

But then we get to the secondary survey, and things get sloppy.

police_frisk1

The secondary survey is supposed to be a quick yet thorough physical exam, both front and back. But all too often it’s quick, and not so thorough. There is the usual laying on of the hands, but barely. Abdominal palpation is usually done well. But little effort is put into checking stability of the pelvis. The extremities are gently patted down with the hope of finding fractures. Joints are slightly flexed, but not stressed at all.

Is it just a slow degradation of physical exam skills? Is it increasing (and misguided) faith in the utility of the CT scanner? I don’t really know. But it’s real!

Bottom line: Watch yourself and your team as they perform the secondary survey! Your goal is to find all the injuries you can before you go to imaging. This means deep palpation, twisting and trying to bend extremities looking for fractures, stressing joints looking for laxity. And doing a good neuro exam! Don’t let your physical exam skills atrophy! Your patients will thank you.

Pet Peeve

Pet Peeve: (Not So) Clever Medical Study Acronyms

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I’m not a big fan of acronyms, although they do serve a purpose. We use them all the time providing medical care. CBC. CTA. CXR. ROSC. And a zillion others. And they can actually be helpful so you don’t have to say or write down some ridiculously long phrase. OMG.

But what really bothers me is the rise of researchers designing clever acronyms for medical studies. The first one , the University Group Diabetes Program (UGDP), was developed in the 1970s. It was actually shortened by journals and media to make for an easier presentation, not by the group themselves.

But then in the 1980s, the Multiple Risk Factor Intervention Trial (MRFIT) came along. It evaluated the impact of multiple interventions on cardiovascular mortality. Mr. Fit. Get it? This was the first of an ever growing number of studies that chose acronyms that were either cleverly related to the work in some way, or that made a catchy new word to help people remember it.

And the number of these acronyms has been growing rapidly. From 1992 to 2002, they increased from 245 to 4100, a 16-fold increase. There are now so many acronyms that many simple ones are being reused. And it seems like studies without an acronym are becoming the minority.

Plus, we’ve moved away from creating pure acronyms like UGDP that are derived from the first letter of each word. Now we use multiple letters from a word, skip some words altogether, or don’t even bother to use the words at all. There are MICHELANGELO, MATISSE, PICASSO, and EINSTEIN studies that were given the name just for the positive association. Nothing to do with the study at all.

This is all a warm-up for my next post, which reviews a geriatric trauma prognosis calculator from the PALLIATE consortium (Prognostic Assessment of Life and Limitations After Trauma in the Elderly). Groan! The title itself almost made me not want to read it. But I am compelled. Tune in Monday.

Reference: SearCh for humourIstic and Extravagant acroNyms and Thoroughly Inappropriate names For Important Clinical trials (SCIENTIFIC): qualitative and quantitative systematic study. BMJ. 2014;349:g7092.