Tag Archives: philosophy

How To Make TEG / ROTEM Useful

A lot of papers have been written on the use of thromboelastography in trauma. And pretty much any meeting or course you may attend has at least one talk on it. And I get it. It can be an important tool in treating trauma patients who have some sort of coagulation disturbance. It helps us figure out what specific part of the coagulation process is out of whack and suggests how we can fix it.

But there are a few problems. And the “friction” that those issues cause overall decreases how useful it is. Here’s a partial list of the problems:

  • The equipment costs money, and the disposables that must be used for every patient do, too.
  • Where do you put the machine? Most hospitals can’t put one unit in every possible area it might be used.
  • How to you get the results to a care area if there is no unit there?
  • There is a significant learning curve for interpreting the results
  • How can it be integrated into the massive transfusion protocol?

The main issue is that the current state of TEG and ROTEM are very similar to the state of electrocardiography shortly after it’s discovery. Here’s what you got then:

In order to get the most from an EKG, you need to combine this tracing with that from other leads, do a bunch of measurements, look for abnormal shapes and elevations/depressions, etc.  This is exactly where we are with TEG and ROTEM today. Relatively crude, and it takes a lot of work to use it.

The tracing below shows where we are with EKGs today. A computer program looks at all the tracings, and rapidly applies a complex set of rules to come to a set of diagnoses. Notice in the image below that this reading is “unconfirmed.” But how many times in your career have you seen a cardiologist correct one of these? The machines are actually very good!

Bottom line: The tracing above is where we need to be with TEG and ROTEM. Instead of a clinician staring at a developing tracing and figuring out what products to give, these machines need to be just like an automated EKG machine. Sure, a human can still stare at the trace. But the machine will automatically monitor it, apply rules about what abnormalities are present and what is needed to correct them. Send off your blood specimen, and within minutes instructions like “infuse 2 units of plasma now” or “give 12u cryo now” appear. These may be displayed on a monitor in the treatment area, or be broadcast to the phone or pager of the responsible clinicians.

Current TEG/ROTEM equipment is what I would consider 1st generation. The next generation will reduce or remove much of the “friction” in the current process and allow us to really integrate TEG/ROTEM meaningfully into the massive transfusion protocol for trauma. And for anyone who develops this 2nd generation equipment, don’t forget my royalty checks for this idea! 

In my next post, I’ll review the new EAST guidelines for the use of TEG and ROTEM.

VIP Syndrome In Healthcare (Very Important Person)

Current events are making this classic post even more poignant!

The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.

Who is a VIP? It may be a celebrity. A family member. Or even a colleague. Or the President of the United States. VIPs (or their healthcare providers) may have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.

Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.

Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.

How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to allproviders who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.

Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.

Yet Another One: The Eleventh Law Of Trauma

If you have followed this blog for any period of time, you are aware of the skepticism I bring to bear when I am reading new material or learning of new ideas. Why is this? Because it is very difficult in this day and age to ascertain the veracity of anything we see, hear, or read.

This is not new compared to, say, a hundred years ago. The media were a bit different, but the underlying issues were the same. There have always been two major factors at play: information overload and the biases built into our human brain operating system.

There is a huge body of new information in every field that is being produced every year. Given the pressures that most researchers are under to publish or perish, a huge number of papers are sent to journals for review. Unfortunately, this leads to a huge number of publications that are of lower quality.

This also contributes to another recognized phenomenon, the half-life of facts. Think about all the things you learned during your training that are no longer believed to be true. Stress causes ulcers. Steroids are good in head injury. There is a definite decay curve for the old facts that occurs as new knowledge is acquired.

So we have a huge amount of potential junk to sort through to figure out what cellular mechanisms are correct or which medications work for a disease. And then we run into our own operating system problems.

All humans have our own innate beliefs that are shaped by experience and all the information we’ve consumed over the years. And we are genetically programmed to do this:
Learn something new  —>  believe it  —>  verify it

And many of us never get to the verify stage because another operating system issue, confirmation bias, takes over. If we learn something that confirms an existing belief, we are much more likely to believe and much less likely to verify. If we learn something that opposes our belief, we still want to believe what we already do and find every flaw in the new data that might refute it.

So here is my eleventh law of trauma:

“Don’t believe anything you learn, especially if it supports what you already believe”

And here is it’s corollary:

“Don’t believe everything you think!”

Bottom line: If you read or hear something new, first examine the source. Is it legitimate and reliable? Where did it get the info? Then check out that source. Critically evaluate it, even if it already supports what you believe. Always treat new information, especially if you think it’s right, as an opportunity to learn something new. Sometimes you will find real gems in the things you thought were wrong, and real crap in the things you believed to be right!

It’s time to flip the algorithm to:
Learn something new  —>  verify it  —>  believe it

Coronavirus (COVID-19) And Your Trauma Service

In my last post, I made some suggestions on how to modify the trauma activation process to better protect your team members from exposure to the Coronavirus. Today, I’ll discuss some things you can do to reduce the exposure of your in-house team that provides care for patients.

First off, I’m not going to discuss the obvious things like personal protective equipment, or what to do when performing risky procedures such as intubation or extubation. Those have been covered elsewhere and each hospital has adopted its own standards.

I will be discussing more general concepts that help limit team member exposure to possible contamination or infected individuals. Here are some of my suggestions:

  • Make sure your hospital conserves the resources it needs to be a trauma center. A certain number of ICUs, operating rooms, and floor beds must be reserved for trauma patients. Your hospital should make contingency plans such that if COVID-19 patients are getting close to taking too many beds or other resources, there is an escape valve so they can be diverted or transferred to other non-trauma hospitals.
  • Save your trauma surgeons for things only they can do. Many hospitals have general surgeons on staff in addition to their trauma/critical care surgeons. Remove the trauma surgeons from emergency general surgery / acute care surgery services and concentrate them on the trauma and critical care services. Have the general surgeons cover the other services, and send all idle trauma surgeons home where it is safer. Rotate them through trauma and critical care on a regular basis. Imagine what would happen if you lose 2 or 3 of your trauma surgeons at the same time, and don’t let it happen to you!
  • Eliminate non-essential meetings and conferences. This includes morbidity and mortality conferences, journal clubs, and all educational conferences. These things have to go on the back burner for now and can be re-instituted once things return to normal.
  • Practice social distancing at essential meetings. Certain gatherings are unavoidable, such as care handoffs (“morning report,” and “afternoon check-out”). Reduce the attendees to only those whose input is critical. If needed, they can gather information from other small groups of providers to prepare for the essential meeting. But no more crowded rooms, please.
  • Don’t congregate with other providers unnecessarily. This means outside your office, in the lounge, and in the lunchroom. The usual social norms need to take a back burner to your own safety and health.
  • Use telephone conferencing as much as possible. You will be surprised at how many of these less-than-essential meetings can be handled virtually, or eliminated. One tip, though: print a copy of the agenda for reference. It seems to be more difficult to follow the flow of the meeting (and take/make notes) if you don’t have something you can visually refer to.
  • Redesign your care team. Do you really need your entire team (APPs, residents, nurses) hanging around all day like they usually do? The reality is that the bulk of the work on any trauma service generally takes place in the morning. The rest of the day is spent waiting for incoming trauma patients. Calculate the optimal number of providers based on your service census. Do the morning work, go on rounds (smaller groups, please), finish any post-rounds chores, then send the extras home. And rotate those providers so that some can spend time at home while the others are in-house.
  • Use residents wisely if you have them. They are part of your care team, too, so be sure to minimize their exposure. The previous tip on redesigning the care team applies to them, too. And frequently, they rotate through several hospitals, many of which are not doing elective surgery. So they may not have a lot to do. Work with the residency program director to see if you can temporarily add them to the trauma center coverage pool. This allows you to keep a larger number of residents at home while maintaining a reasonable number for your care team.

In my next post, I’ll cover changes you should consider in your Massive Transfusion Protocol.

Coronavirus (COVID-19) And Your Trauma Team

We are in the midst of Coronavirus mania! Every hospital in the country is scrambling to figure out what to do to meet the rapidly increasing demand for screening and access to care that has been so unexpectedly thrust upon us.

Trauma professionals will be profoundly affected as well. We are a scarce resource in the first place, and I’m speaking of those in all disciplines from prehospital through rehab. And since the SARS-CoV-2 virus seems to be so widespread and our testing abilities so limited, it is a challenge to protect ourselves from contracting it. Given how scarce we are, losing even a few to self-imposed quarantine (or worse) would be very disruptive to the health care of the trauma patients we normally take care of.

The key is to try to limit exposure to the Coronavirus as much as possible. Hospitals are now very diligent about screening patients and their families as they enter the hospital. However, the trauma activation patient is a potential wild card.

What can be done to protect the trauma professionals assembling to take care of a trauma activation patient, who should probably be considered infected until proven otherwise? The most obvious answer is to escalate the normal personal protective measures to include the same garb worn for treating patients with known or suspected infection. This includes N95 masks and full face shields.

Unfortunately, this is not practical due to the extreme shortages of this equipment. But what we can do is optimize our trauma team and provide a more informed and graduated response.

Here are my recommendations:

  • Drastically reduce overtriage. Most busy trauma centers have overtriage rates (trauma activation for patients with low acuity and/or do not meet activation criteria) around 50%, and sometimes higher. Frequently, these are patients who did not really need to be met by the full trauma team. How can you do this?
    • Eliminate superfluous activation criteria; keep only your physiologic and anatomic ones. These generally correlate with Steps 1 and 2 of the CDC triage criteria for transfer to a trauma center used by your EMS providers. Eliminate all mechanism of injury criteria except for penetrating injury. This includes falls, pedestrian struck, vehicle intrusions, etc. Then eliminate anything else that doesn’t fall into these categories. You are essentially converting to a bare bones single-tier activation system.
    • Eliminate the ability of prehospital providers to call a field activation on anything other than your activation criteria (or Step 1 and Step 2 CDC criteria. This may be difficult or confusing if they service several centers that normally have different criteria. The person taking the radio/phone call and initiating the team page should not activate the team unless one of the physiologic or anatomic criteria are specifically mentioned. All other transports should be met by an emergency physician who will then use their clinical judgement to activate the full team.
  • Eliminate superfluous trauma team members. This includes students, shadowing providers, observers, extra residents, and anyone else who does not have an essential role in the room.
  • Call the entire team, but only use who you need. Determine the makeup of your core team. One physician, two nurses, a tech, and a scribe? This will vary by center. They should dawn protective gear that is as effective (and available) as possible. (This may not be face shields and N95 masks if you are a busy center and don’t have many in stock.) The others should remain available outside the room and be called in only if necessary (pharmacist, respiratory therapy, additional physicians or APPs, etc). All other normal team personnel can then be dismissed and disperse.
  • Release active team members who are no longer needed. As the resuscitation winds down and team members complete their tasks, send them away.
  • Reduce the post-resuscitation transport team to the minimum necessary. This will depend on the patient’s condition. Are they stable, awake, and alert? Or intubated and traveling with a rapid infuser? Assign personnel appropriately.

Bottom line: Things have changed for a while and the old rules may not completely apply. Critically look at everything you do to see if it is still reasonable and necessary. Always keep the safety of your patient at heart. But don’t lose sight of the fact that you won’t be able to help anyone in the future if you are quarantined at home.

This crisis will only last for a few months, but it should cause us to question business as usual. We may discover that some of what we do is not a necessary as we thought!

I’m very interested in what others are doing with their resuscitation teams and trauma services to increase safety. Please share on Twitter, or feel free to email me.