Okay, so you’ve seen “other people” wearing perfectly good lead aprons lifting them up to their chin during portable x-rays in the trauma bay. Is that really necessary, or is it just an urban legend?
After hitting the medical radiation physics books (really light reading, I must say), I’ve finally got an answer. Let’s say that the xray is taken in the “usual fashion”:
Tube is approximately 5 feet above the xray plate
Typical chest settings of 85kVp, 2mAs, 3mm Al filtration
Xray plate is 35x43cm
The calculated exposure to the patient is 52 microGrays. Most of the radiation goes through the patient onto the plate. A very small amount reflects off their bones and the table itself. This is the scatter we worry about.
So let’s assume that the closest person to the patient is 3 feet away. Remember that radiation intensity diminishes as the square of the distance. So if the distance doubles, the intensity decreases to one fourth. By calculating the intensity of the small amount of scatter at 3 feet from the patient, we come up with a whopping 0.2 microGrays. Since most people are even further away, the dose is much, much less for them.
Let’s put it perspective now. The background radiation we are exposed to every day (from cosmic rays, brick buildings, etc) amounts to about 2400 microGrays per year. So 0.2 microGrays from chest x-ray scatter is less than the radiation we are exposed to naturally every hour!
The bottom line: unless you need to work out you shoulders and pecs, you probably don’t bother to lift your lead apron every time the portable x-ray unit beeps. It’s a waste of time and effort! Just stand back and enjoy!
Trauma Team members typically wear a lead gown under their personal protective equipment so they don’t have to run out of the room when x-rays are taken. How often do you see people do this?
Is it really necessary? Or is it just a way to exercise your pecs and biceps? Tomorrow I’ll talk about how much radiation team members are really exposed to so you can decide if this is really necessary.
Everyone worries about patient satisfaction these days, and rightly so. There’s quality of care, and there’s satisfaction with it. The two are tough to separate. Many hospitals administer surveys and questionnaires after discharge about the overall hospital stay. But who looks at the experience of going through a trauma activation?
A very recent paper from Cornell and Penn interviewed trauma patients within 2 days of the trauma activation, and provided a $25 incentive to participate. There were 14 questions presented during a verbal interview, all open-ended. Patients with abnormal mental status during trauma activation were excluded, and data was collected over a 7 month period.
Here are the factoids:
Most patients described fear and agitation, along with a loss of control
93% expressed concern about things other than themselves: family, work, safety
Many patients remarked on the removal of their clothing. Some were concerned that they could not afford to replace them.
Most participants noted that they received pain medicine early, but that it was not always effective immediately
All participants described the team as caring and expert at what they do
Patients appreciated the fact that team members introduced themselves and expressed concern for their wellbeing
They were very observant of communication, and picked up on sidebar communications as well
Bottom line: Don’t underestimate what your patient observes and experiences during a trauma resuscitation. Unless head injured or intoxicated, they are picking up on everything you say and do. The trauma activation needs to be as patient-centered as possible while maintaining patient and team safety. Team members should be mindful of all communications, even when things are winding down. Try to spare patient clothing if possible. Use adequate analgesia and judicious sedation. And always remember to communicate clearly!
Over the past two days, I’ve discussed a method for optimizing the hand-off process between prehospital providers and the trauma team. Besides improving the quality and completeness of information exchange, it also fosters a good relationship between the two. All too often, the medics feel that “the trauma team is not listening to me” if the procedure is to move the patient onto the ED bed as quickly as possible.
And they are right! As soon as the patient hits the table, the trauma team starts doing what they do so well. It’s impossible for humans to multi-task, even though they think they can (look at texting and driving). We switch contexts with our brain, from looking at the patient to listening to EMS, back and forth. And it takes a few extra seconds to switch from one to the other. Team members will not be able to concentrate on the potentially important details that are being relayed.
What should you do if the team doesn’t want to wait?
First, educate them. Except for those who are in extremis or arrest, the patient can wait on the EMS stretcher for 30 seconds. Nothing harmful is going to happen in that short period.
Then, create a hard stop. The easiest way to do this is to place a laminated copy of the timeout procedureon the ED bed. And the rule is that the card doesn’t move until the timeout is done. This is very similar to what happens in the OR. The process should take only 30 seconds, then it’s over and the team can start.
I wrote about handoffs between EMS and the trauma team yesterday. It’s a problem at many hospitals. So what to do?
Let’s learn from our experience in the OR. Best practice in the operating room mandates a specific time out process that involves everyone in the OR. Each participant in the operation has to stop, identify the patient, state what the proposed procedure and location is, verify that the site is marked properly, and that they have carried out their own specific responsibilities (e.g. infused the antibiotic).
Some trauma centers have initiated a similar process for their trauma team as well. Here’s how it works:
The patient is rolled into the resuscitation room by EMS personnel, but remains on the stretcher.
Any urgent cares continue, such as ventilation.
The trauma team leader is identified and the EMS lead gives a brief report while everyone in the room listens. The report consists of only mechanism, all identified injuries, vital signs (including pupils and GCS), any treatments provided. This should take no more than 30 seconds.
An opportunity for questions to be asked and answered is presented
The patient is moved onto the hospital bed and evaluation and treatment proceed as usual.
EMS personnel provide any additional information to the scribe, and may be available to answer any additional questions for a brief period of time.
Bottom line: This is an excellent way to improve the relationship between prehospital and trauma team while improving patient care. It should help increase the amount of clinically relevant information exchanged between care providers. Obviously, there will be certain cases where such a clean process is not possible (e.g. CPR in progress). I recommend that all trauma programs consider implementing this “Trauma Activation Time Out For EMS” concept.
Tomorrow, I’ll share a best practice to make this process even better!
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