Tag Archives: trauma team

Best Of: Why Did The Trauma Team Cut Off My Clothes?

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.

Why Did The Trauma Team Cut Off My Clothes?

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.

How Much Radiation is the Trauma Team Really Exposed To?

Okay, so you’ve seen “other people” wearing perfectly good lead aprons lifting them up to their chin during portable xrays 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 xray 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, don’t bother to lift your lead apron every time the portable xray unit beeps. It’s a waste of time and effort!

Prehospital To Trauma Team Handoff: A Solution

I’ve written about handoffs between EMS and the trauma team over the past two days. 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.


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EMS Handoff: Comments

I received quite a bit of feedback from yesterday’s column. Obviously this topic strikes a chord with my readers. Here was one well thought out comment from Tim Kaye in California:

I have worked for 15 years as a paramedic in a very busy EMS system in Northern California. When I was new, I used to fight to make myself heard in the trauma room, only adding to the din and chaos, which was usually – and rightly so – squelched by a decisive bark from the trauma team leader for quiet as they assesed the critical patient. What I came to realize was that if I wanted to benifit my patient, I needed to re-invent how I was taught to give my reports. Instead of trying to include everything in a minutes-long speech, I would instead follow this pattern:

1) Ask as I was walking in who I would give report to, thereby establishing clear communication and not just shouting to no one in particular.

2) A very brief, one sentence explination of MOI, and I forced myself to hold fast to the one sentence rule.

3) Critical findings/life-threats were reported next, followed by any interventions. This gave the trauma team leader an idea of where to focus their exam for similar life-threats.

4) I would give only selected vital signs in my rapid report. These included anything aberant or concering, followed by heart rate, respiratory rate and end-tidal CO2 on all patients.

5) I would conclude by asking the trauma team leader specifically if they had any immediate questions.

Because I structure and practice this method, my reports typically last about 20-30 seconds. Realizing that there are major gaps in the initial report, I then go and speak directly to the scribe and fill in those gaps with such information as further description of MOI, a complete set of vital signs and trends, blood glucose, IV sites, etc.

This method allows for rapidly communicating vital information quickly, and detailed information to the appropriate staff member at the appropriate time.

To tie up any loose ends, after I completed my charting, I ALWAYS stop by the trauma bay and check one last time with both the trauma team leader and the scribe and ask if they have any more questions. As I made this my practice, ER attendings, trauma surgeons and nurses all came to expect this final check-in to clear up any last questions. This worked in a most excellent fashion to provide continuity of care, to develop relationships with all of the staff at our two Level-1 and one Level-2 centers, and for personal education as I checked in to what the diagnosis and course of treatment was for the patient.

I would argue that the handoff is really a two-way process. Tim has found a way to do the right thing in an environment where the other half of the team is too busy / not listening / not aware.

Tomorrow I’ll share what I think is the best approach to this process. Hint: it involves active participation by both sets of trauma professionals.

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