Tag Archives: pet peeve

The Trauma Activation Pat-Down?

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: (Not So) Clever Medical Study Acronyms

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.

Why Is My Trauma Patient On Oxygen?

How many times has this happened to you? You walk into a young, healthy trauma patient’s room and discover that they have nasal prongs and oxygen in place. Or better yet, these items appear overnight on a patient who never needed them previously. And the reason? The pulse oximeter reading had been “low” at some point.

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This phenomenon of treating numbers without forethought has been one of my pet peeves for years. Somehow, it is assumed that an oximetry value less than the standard “normal” requires therapy. This is not the case.

In young, healthy people the peripheral oxygen saturation values (O2 sat) are typically 96-100% on room air. As we age, the normal values slowly decline. If we abuse ourselves (smoking, working in toxic environments, etc), lung damage occurs and the values can be significantly lower. Patients with obstructive sleep apnea will have much lower numbers intermittently through the night.

So when does a trauma inpatient actually need supplemental oxygen? Unfortunately, the literature provides little guidance on what “normal” really is in older or less healthy patients. Probably because there is no norm. The key is that the patient must need oxygen therapy.

But how can you tell? Examine them! Talk to them! If the only abnormal finding is patient annoyance due to the persistent beeping of the machine, they don’t need oxygen. If they feel anxious, short of breath, or have new onset tachycardia, they probably do. Saturations in the low 90s or even upper 80s can be normal for the elderly and smokers.

Bottom line: Don’t get into the habit of treating numbers without thinking about them. There are lots of reasons for the oximeter to read artificially low. There are also many reasons for patients to have a low O2 sat reading which is not physiologically significant. So listen, talk, touch and observe. Set the alarm level to 90%, or even lower. And if your patient is comfortable and has no idea that their O2 sat is low, turn off the oxygen and toss the oximeter out the window.

The Trauma Activation Pat-Down?

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.

Cognitive Bias – Don’t You Hate It When They Do That?

cognitive_bias

Source: http://chainsawsuit.com/comic/2014/09/16/on-research/

I sat in on a committee meeting once where the management of a particular clinical problem was being vigorously discussed. One of the participants pulled out his smartphone, did a quick search, and said, “Aha! This article shows that my opinion is correct!”

This approach is wrong on so many levels, it’s almost laughable. But it illustrates a real weakness that all human beings have: susceptibility to cognitive bias. 

Scientists have identified somewhere between 150 and 200 different types of cognitive bias, and trying to sort them out will literally make your head spin. For a quick and enlightening read, I recommend reading the article below. It sifts through the mess and lumps them into four understandable categories.

Bottom line: We are all capable of warping what we read, hear, and see to fit our own vortex of pre-existing beliefs. It’s very important to recognize the possibility of bias when you are seeking information so that you can do everything to minimize its impact. If you can’t or won’t do that, then you’ll end up being that know-it-all guy with the smartphone.

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