Tag Archives: philosophy

The First Law Of Trauma

Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.

The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Some examples:

  • An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
  • A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
  • A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.

Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.

Other Laws of Trauma:

Are “Routine” Vital Signs Really So Routine?

Trauma professionals, particularly physicians, tend to take vital signs for granted on patients who are admitted to the hospital. And we tend to assume that our patients won’t ask questions, either. Unfortunately, they usually don’t.

“Routine” vital signs tend to get measured by the nurses once a shift. But think about that for a minute. In the US, the typical shifts run from 7 am to 3 pm, 3 pm to 11 pm, and 11 pm to 7 am. This means that at some point in the night, they will be disturbed to take their blood pressure and pulse. At least! And what if they need to have a neuro exam, pulse checks, or to have that beeping pulse oximeter hooked up?

And even though the shift runs from 11 pm to 7 am, does that mean the vitals will be take at the beginning or end of shift? No way! The nurse has to receive report for a safe handoff and get organized at the start of the shift. And how many patients does he or she have? They may not be able to check vitals on everybody until after midnight. And what if vitals are ordered to be taken more than once a shift? How can any patient get decent sleep? 

Bottom line: Once again, think carefully about the orders! It’s no wonder some of our elderly patients sundown when they are admitted to the hospital. How can anyone get a good night’s sleep there? 

Don’t just reflexively write for a frequency. Think about how often your patient really needs to be disturbed, especially at night. If they are recovering uneventfully from an orthopedic procedure, why bother them at all at night? And nurses, make it your responsibility to advocate for your patient and bring up these crazy orders so they can be fixed.

Gunshots And CT Scan Of The Abdomen

Abdominal gunshots and CT scanning are usually thought to be mutually exclusive. The usual algorithm generally means a prompt trip to the operating room. But as with many things in the management of trauma, there are always exceptions. The key is to understand when exactly one of those exceptions is warranted.

Exception 1: Did it really enter the abdomen? Gunshots have enough energy that they usually do get inside. However, freaky combinations of trajectory and body habitus do occur. There are three tests that must be passed in order to entertain the possibility that the bullet may not have made it inside your patient: physiology, anatomy, and physical exam. For physiology, the patient must be completely hemodynamically stable. Anatomically, the trajectory must make sense. If the known wounds and angles allow a tangential course make sense, then fine. But if there is a hole in the epigastrium and another next to the spine, you have to assume the bullet went straight through. Finally, the physical exam must be normal. No peritonitis. No generalized guarding. Focal tenderness only in the immediate area of any wounds. If all three of these criteria are passed, then a CT can be obtained to demonstrate the trajectory.

Exception 2: Did it enter an unimportant area of the abdomen? Well, there’s really only one of these, and that’s the area involving the right lobe of the liver and extending posteriorly and lateral to it. If the bullet hole(s) involve only this area, and the three tests above are passed, CT may confirm an injury that can be observed. However, there should only be a minimal amount of free fluid, and no soft tissue changes of any kind adjacent to bowel.

Exception 3: A prompt trauma lap was performed, but you think you need more information afterwards. This is rare. The usual belief is that the eyes of the surgeon provide the gold standard evaluation during a trauma lap. For most low velocity injuries with an easily understood trajectory, this is probably true. However, high velocity injuries, those involving multiple projectiles, or complicated trajectories (side to side) can be challenging for even the most experienced surgeon. Some areas (think retroperitoneum or deep in the pelvis) are tough to visualize completely, especially when there’s blood everywhere. These are also the cases most likely to require damage control surgery, so once the patient has been temporarily closed, warmed and resuscitated, a quick trip to CT may be helful in revealing unexpected shrapnel, unsuspected injuries, or other issues that may change your management. Even a completely unsurprising scan can provide a higher sense of security.

Bottom line: CT of the abdomen and gunshots to that area may actually coexist in some special cases. Make sure the physiology, anatomy and physical exam criteria are passed first. I also make a point of announcing to all trainees that taking these patients to CT is not the norm, and carefully explain the rationale. Finally, apply the concept of the null hypothesis to this situation. Your null hypothesis should state that your patient does not need a CT after gunshot to the abdomen, and you have to work to prove otherwise!

When Is It Too Late To Call A Trauma Activation?

Admit it. It’s happened to you. You get paged to a trauma activation, hustle on down to the ED, and get dressed. The patient is calmly and comfortably lying on a cart, staring at you like you’re from Mars. Then you hear the story. He has a grade V spleen injury. But he just got back from CT scan. And his car crash was yesterday

Is this appropriate? The answer is no! But, as you will see, the answer is not always as obvious as this example. The top thing to keep in mind in triggering a trauma activation appropriately is the reason behind having them in the first place.

The entire purpose of a trauma activation is speed. The assumption must be that your patient is dying and you have to (quickly) prove that they are not. It’s the null hypothesis of trauma.

Trauma teams are designed with certain common features:

  • A group of people with a common purpose
  • The ability to speed through the exam and bedside procedures via division of labor
  • Rapid access to diagnostic studies, like CT scan
  • Availability of blood products, if needed
  • Immediate access to an OR, if needed
  • Recognition in key departments throughout the hospital that a patient may need resources quickly

Every trauma center has trauma activation triage criteria that try to predict which patients will need this kind of speed. Does the patient in the example above need this? NO! He’s already been selected out to do well. Why, he’s practically finished the nonoperative solid organ management protocol on his own at home.

Here are some general rules:

  • If the patient meets any of your physiologic and/or anatomic criteria, they are or can be sick. Trigger immediately, regardless of how much time has passed.
  • If they meet only mechanism criteria and it’s been more than 6 hours since the event, they probably do not need the fast track.
  • If they only meet the “clinician / EMS judgment” criteria, think about what the suspected injuries are based on a quick history and brief exam. Once again, if more than 6 hours have passed and there are no physiologic disturbances, the time for needing a trauma activation is probably past.

If you do decide not to trigger an activation in one of these cases, please let your trauma administrative team (trauma medical director, trauma program manager) know as soon as possible. This may appear to be undertriage as they analyze the admission, and it’s important for them to know the reasoning behind your choice so they can accurately document under- and over-triage.

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Doctor, I Fell On That Knife! Really!?

I’ve had this mechanism of injury described about once a year for my entire career.

“I was just washing the dishes, and I dropped a knife while I was drying it. When I went to pick it up, I lost my balance and tripped over the rug in front of my sink. Then I fell down on the knife, and there you have it”.

What does it really mean?

First, think about physics. Most knives do not land standing straight up. They don’t even land on their side with the blade side up. They land flat with the sharp side perpendicular to anything that might fall on top of it.

Then think about Occam’s razor. You remember, Sir William of Occam back in the 1300’s. He popularized the principle of parsimony in problem solving. What does this mean? If you have more than one possible explanation (or hypothesis) for an event, the simplest one should be selected. Well, the falling down “hypothesis” is way too complicated.

What does it really mean? Your patient either stabbed themself (most common reason), or they are trying to protect the person who really did it (significant other). What to do? Interrogate them, asking the same thing over and over. Ask for exact details. Ask until the story changes. Have other people ask. Sooner or later, you’ll get the answer you were expecting. Then get the appropriate professionals involved to help with the problem (psych, law enforcement, etc).