Tag Archives: trauma team

Philosophy

Why Did The Trauma Team Cut Off My Clothes?

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The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting.

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.

Imaging

The Lead Gown Pull-Up: Part 2

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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!

Prehospital

Making The Trauma Team Time Out Even Better!

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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 procedure on 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.

Here’s a copy of a sample TTA Timeout card:

Download a TTA timeout card

Modify it to suit your hospital and process, and try it out!

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Thanks to the trauma team at Ridgeview Hospital in Waconia MN for telling me about this cool trick!

General

Prehospital To Trauma Team Handoff: A Solution

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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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