Figure It Out!
Here’s a test of your observational skills and trauma knowledge. This picture tells you everything you need to know. What happened, and what’s the likely diagnosis?
Answer tomorrow!
Source: Private archive. Patient not treated at Regions Hospital
Over the years, I’ve seen the trauma teams at quite a few hospitals in action. One thing I have noticed is that most just don’t pay attention to what they wear. I’m talking about wearing personal protective equipment again. It’s one of those things, like hand washing, that everyone knows that they are supposed to do.
There are two reasons to put all that stuff on:
The minimum equipment that MUST be worn is a cap of some sort (to keep your hair from falling on the patient), mask and eye protection (mucus membrane protection), gown (protects your clothes), and gloves (obvious). Shoe protection is optional, in my opinion, unless you wear Christian Louboutin to work.
So you’ve been lax with your team. How do you get them to put everything on now? It’s like getting your child to wear a bicycle helmet when they are fourteen.
The top picture shows part of our trauma team assembling before a trauma activation. Everyone is dressed. They know that someone will call them on it if they aren’t. Also, note the little pink sticker on the chest of physician at the head of the bed. We have a sticker for every role in the room (bottom picture). At the beginning of a resuscitation I scan the room to make sure everyone has one. It helps identify everyone and makes extraneous personnel stand out so they can be asked to leave the room.
Bottom line: Everyone has to wear their personal protective equipment on every trauma resuscitation. No exceptions.
Related post:
Minority Report In The OR
The movie “Minority Report” showed an interesting way to manipulate visual data using hand gestures. It required a special glove and used large transparent display surfaces. Microsoft has helped make this achievement both easy and cheap using their Kinect controller using a combination of visual and infrared imaging.
Now Siemens Healthcare has embraced this technology and developed a hands-off image manipulation system for use in the OR. The Kinect system projects an infrared grid into the room and records them using an offset camera. This allows the system to construct a 3D representation of objects in the room. The Kinect software can identify movements and objects using this data.
Siemens is using special software with the Kinect that allows it to detect and interpret fine movement of a surgeon’s hands in the operating room. The final product will allow a surgeon to browse, pan and zoom relevant patient images while they remain scrubbed and sterile, just by gesturing with their hands. This product will be tested in two hospitals in the near future.
Here’s my prediction: why will we need a big, clunky robotic system interface like DaVinci? Just have the surgeon sit in a comfortable chair, waving their hands to move the laparoscopic camera and instruments. I see especially interesting applications of this technology in military settings and in space!
Reference: Siemens Game Console Technology
There’s been renewed interest among my readers regarding trauma flow sheets and the EMR. This is an update on information from a previous post.
There is a continuing push by hospital administrations nationwide to move toward the use of electronic medical record (EMR) systems in hospitals. In the US, much of this is being driven by the Meaningful Use initiative by CMS. There are a number of benefits from using such systems, including but not limited to:
Unfortunately, many hospitals or hospital system IT departments are insistent in moving all charting to the EMR, including the trauma flow sheet. For some, it is a revenue enhancement tool that takes advantage of improved documentation by ED physicians. For others, it is a result of the irrational urge to make everything paperless.
As a trauma center reviewer, I have had the privilege of visiting many hospitals and inspecting their trauma flow sheet charting tools. The bottom line is that I have still not found an electronic medical record system that can replace the handwritten trauma flow sheet.
A trauma team activation is a complex, fast-paced, finely orchestrated performance that does not lend itself well to being recorded electronically. There are two major problems:
There is so much information being transferred nearly simultaneously (vital signs, physical findings, procedures, fluid volumes given, laboratory and radiology orders, narratives) that it is not possible to record it completely and accurately using any current computer data entry interface or medical record system. Frequently, it ends up being recorded by hand on another piece of paper and is then entered later into the EMR. This is easily spotted by trauma reviewers.
The reporting features of virtually all EMRs allow for a listing of events sorted one way or another. It is rarely graphical in nature, and typically spans many, many pages of text output. Charts that I have reviewed have “reports” ranging from 8 to 20+ pages. It is virtually impossible for a human being to read through this type of output and reconstruct the flow of a trauma resuscitation. In many PI review cases, the trauma program manager is reduced to transcribing the individual data items from the EMR back onto a paper trauma flow sheet in order to conceptualize the resuscitation. Frequently, trauma reviewers identify care problems during the trauma activation that were buried in all the report output.
IT personnel may claim that the problem is an “end user failure.” It’s not. I defy any of them to come to a trauma resuscitation and rapidly and accurately transcribe all of the information presented, or try to review a PI case based on a printed EMR report.
The real bottom line: trauma flow sheets (and other similar code sheets) can not and should not be reduced to electronic data entry. It is not only frustrating, but will hamper the trauma PI process. If the reviewers find that the impact on the trauma PI program is significant, it may result in a PI criterion deficiency and can jeopardize a trauma center’s verification status!
Related post:
One of the more commonplace recommendations for recovery from mild traumatic brain injury (TBI) is “cognitive rest.” Sports medicine professionals recommend it, physiatrists recommend it, and trauma professionals talk about it.
First, what is it, exactly? I’ve seen a number of descriptions, and they vary quite a bit. The main concept is to avoid all activities that involve mental exertion. This includes using a computer, watching TV, talking on a cell phone, reading, playing video games, and listening to loud music. Huh?
What good does this allegedly do? Most articles that I’ve read theorize that cognitive activity somehow increases the metabolic activity of the brain and that this is bad. One of the more interesting papers I read (from 2010!) says it best: “It is now well-accepted that excessive neurometabolic activity can interfere with recovery from a concussion and that physical rest is needed.”
Read carefully. Well-accepted. The paper cites unpublished data on children by one of the authors, 2 meta-analyses and 2 consensus opinions. In other words, no data at all. Yet somehow the concept has caught on.
First of all, I don’t think it’s possible for most people to realistically practice cognitive rest. Who knows if there is really any difference in metabolism and energy use by the brain if you are engaging in any of the banned activities above? And let’s go to the other extreme: if one lies quietly in bed meditating, shouldn’t this be the ultimate cognitive rest? Yet fMRI and PET studies suggest (also limited data) that cerebral flow in specific areas of the brain increases during this state.
Maybe a modest increase in activity is good. Physical activity (within limits) has been shown to be very beneficial to physical and psychological well being time and time again. And the only paper I could find on the topic with respect to TBI showed that randomization to bedrest vs normal physical activity had no difference in post-concussive syndrome incidence or severity. However, the active group recovered with significantly less dizziness.
Bottom line: There is no data to support the concept of cognitive rest. Any type of activity, either mental or physical, can cause fatigue in a variable amount of time in people with mild TBI. It is probably best to interpret this as a signal to take it easy and recover for a while before exerting oneself again. But so far there is no objective data to show that cognitive activity either helps or hinders recovery.
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