A Brief History of the Electronic Health Record

The EHR has been around longer than you think. Even before the current desktop style microcomputers existed, a few hospitals implemented early versions of this product. One of the first was the Latter Day Saints Hospital in Salt Lake City. It installed what it called the HELP system, an acronym for Health Evaluation through Logical Programming.

As computing power increased and the size of the computer box and its cost decreased, a series of advances in medical software systems began to occur. In 1983, a software product geared toward resource scheduling was introduced, and became one of the leading applications of its kind. Most people recognize the name Cadence, but few realize that this was one of the earliest product releases from Epic Systems Corporation.

In 1988, the US government contracted out to develop an electronic record system for the military, much of which is still in use today. On a smaller scale, PC type computers were almost 10 years old in 1990 when Microsoft introduced what I consider the first real version of Windows, version 3.0. Epic was once again an innovator, and it released a product called EpicCare for Windows.

Beginning in 2004, there was a move within the government to emphasize implementation of EHRs across the US, spearheaded by President George W. Bush. And as expected, this led to a number of products developed by a variety of software makers. The push to roll out an EHR universally continues to this day, with no end in sight.

Is this a good thing or a bad one? Although much maligned, the EHR can certainly offer benefits. However, like anything touted as a miracle drug or device, there are always downsides. I’ll review both over the course of the week, but my focus will be on one very specific trauma problem: use of the EHR during trauma resuscitation. Many trauma programs either voluntarily adopted the use of an electronic trauma flow sheet (eTFS), or were forced into it by their hospital administration or IT department. Good idea or not?

We shall see…

Source: The Trauma Professionals’s Blog

Trauma And The Electronic Health Record

I’m going to dedicate this week to discussing the impact of the electronic health record (EHR) on trauma care.

First, I’ll talk a little about the history of the EHR, how it came about and why it was “encouraged” of all hospitals. I’ll also look at who the big players are. Next, I’ll review two studies of the impact of the EHR on ED productivity and patient stay.

And finally, I’ll really dig into using an electronic trauma flow sheet that interfaces with the EHR. My thinking has slowly been changing, but not by much. I’ll review my reasons, and talk about the (few) success stories that are out there.

Stay tuned!

Source: The Trauma Professionals’s Blog

Why Do They Call It: The Surgical Neck of the Humerus?

Anatomy is complex and confusing at times. Pretty much everything you can find in the human body has a name. Sometimes it makes sense. Sometimes it’s named after someone famous. And sometimes, it’s just a head-scratcher.

Let’s take the surgical neck of the humerus. Here’s an image of the proximal humerus:

proximal_humerus-14a181ca9b3646a88cc1

Notice there are two different “necks” of the humerus. You are probably familiar with the anatomic neck from your anatomy classes. But if you are a resident, an orthopedic surgeon, or someone who deals with fractures regularly, you are more familiar with the surgical neck.

The surgical neck of the humerus is the most common fracture site on the proximal humerus.  But here’s the kicker. It’s a misnomer!

Just because you see a fracture of the surgical neck of the humerus doesn’t meed it needs surgery! Indeed, many of these fractures are now successfully treated with immobilization in a sling. Your friendly neighborhood orthopedic surgeons will assess fracture stability by looking at the mechanism, exact location, involvement of the tubercles, and motion. Then they will decide on their treatment plan.

Bottom line: Don’t get suckered when someone asks you what operation is usually needed for a fracture of the surgical neck of the humerus!

Related posts: 

Source: The Trauma Professionals’s Blog

How Fast Can You Warm Up A Hypothermic Patient?

‘Tis the season to see hypothermic patients again! The optimal way to warm them up has been debated for years. A number of very interesting techniques have been devised. Ever wonder how fast / effective they are?

I’ve culled data from a number of sources, and here is a summary what I found. And of course, the disclaimer: “your results may vary.”

Warming Technique Rate of Rewarming
Passive external (blankets, lights) 0.5° C / hr
Active external (lights, hot water bottle) 1 – 3° C / hr
Bair Hugger 2.4° C / hr
Hot inspired air in ET tube 1° C / hr
Fluid warmer 2 – 3° C / hr
GI tract irrigation (stomach or colon, 40° C fluid, instill for 10 minutes, then evacuate) 1.5 -3° C / hr
Peritoneal lavage (instill for 20-30 minutes) 1 – 3° C / hr
Thoracic lavage (2 chest tubes, continuous flow) 3° C / hr
Continuous veno-venous rewarming 3° C / hr
Continuous arterio-venous rewarming 4.5° C / hr
Mediastinal lavage (thoracotomy) 8° C / hr
Cardiopulmonary bypass 9° C / hr
Warm water immersion (Hubbard or therapy tank) 20° C / hr

Source: The Trauma Professionals’s Blog

Why Is NPO The Default Diet For Trauma Patients?

I’ve watched it happen for years. A trauma patient is admitted with a small subarachnoid hemorrhage in the evening. The residents put in all the “usual” orders and tuck them away for the night. I am the rounder the next day, and when I saunter into the patient’s room, this is what I find:

They were made NPO. And this isn’t just an issue for patients with a small head bleed. A grade II spleen. An orbital fracture. Cervical spine injury. The list goes on.

What do these injuries have to do with your GI tract?

Here are some pointers on writing the correct diet orders on your trauma patients:

  • Is there a plan to take them to the operating room within the next 8 hours or so? If not, let them eat. If you are not sure, contact the responsible service and ask. Once you have confirmed their OR status, write the appropriate order.
  • Have they just come out of the operating room from a laparotomy? Then yes, they will have an ileus and should be NPO.
  • Are they being admitted to the ICU? If their condition is tenuous enough that they need ICU level monitoring, then they actually do belong to that small group of patients that should be kept NPO.

But here’s the biggest offender. Most trauma professionals don’t think this one through, and reflexively write for the starvation diet.

  • Do they have a condition that will likely require an emergent operation in the very near future? This one is a judgment call. But how often have you seen a patient with subarachnoid hemorrhage have an emergent craniotomy? How often do low grade solid organ injuries fail if they’ve always had stable vital signs? Or even high grade injuries? The answer is, not often at all! So let them eat!

Bottom line: Unless your patient is known to be heading to the OR soon, or just had a laparotomy, the default trauma diet should be a regular diet! 

Source: The Trauma Professionals’s Blog

New Trauma MedEd Newsletter Released Soon!

I’m just putting the finishing touches on the next newsletter. It contains everything that you really want to know about Trauma in Pregnancy. Here are the contents:

  • Predicting outcomes
  • Tips & Tricks (for EMS and physicians)
  • Imaging
  • Peri-mortem C-section: when, with what, and how?

I’m going to release this issue to subscribers on Halloween. Everyone else can pick it up here on the blog about 10 days later.

If you want to get it as soon as it is released, please subscribe by clicking here! And you can pick up back issues when you follow the link, too!

tmeimage1116

Source: The Trauma Professionals’s Blog

What You Need To Know About Frontal Sinus Fractures

Fracture of the frontal sinus is less common than other facial injuries, but can be more complex to deal with, both in the shorter and longer terms. These are generally high energy injuries, and facial impact in car crashes is the most common mechanism. Fists generally can’t cause the injury, but blunt objects like baseball bats can.

Here’s the normal anatomy:

sinus-fracture-treatment

 

Source: www.facialtraumamd.com

There are two “tables”, the anterior and the posterior. The anterior is covered with skin and a small amount of subcutaneous tissue. The posterior table is separated from the brain by the meninges.

Here’s an image of an open fracture involving both tables. Note the underlying pneumocephalus.

frontal_sinus1

A third of injuries violate the anterior table, and two thirds violate both. Posterior table fractures are very rare. A third of all patients will develop a CSF leak, typically from their nose.

These fractures may be (rarely) identified on physical exam if deformity and flattening is noted over the forehead. Most of the time, these patients undergo imaging for brain injury and the fracture is found incidentally. Once identified, go back and specifically look for a CSF leak. Clear fluid in the nose is, by definition, CSF. Don’t waste time on a beta-2 transferring (see below).

If a laceration is clearly visible over the fracture, or if a CSF leak was identified, notify your maxillofacial specialist immediately. If more than a little pneumocephalus is present, let your neurosurgeon know. Otherwise, your consults can wait until the next morning.

In general, these patients frequently require surgery for the fracture, either to restore cosmetic contours or to avoid mucocele formation. However, these are seldom needed urgently unless the fracture is an open fracture with contamination or there is a significant CSF leak. If in doubt, though, consult your specialist.

Related posts:

Source: The Trauma Professionals’s Blog

Using Your Hybrid OR For Trauma

Every hospital wants some gadget or other. First, it was a robot. Or two. Now, it’s a hybrid operating room.

lourdes-hybrid-or1

What is this, you ask? It’s a mashup of an operating room and an interventional radiology suite. It’s new. It’s big. It’s cool (literally, which is an issue for trauma surgeons).

More and more hospitals are adding hybrid rooms at the request of their vascular surgery teams. These rooms allow for both angiographic and open operative procedures, potentially at the same time. They are perfect for endovascular procedures that need some degree of hands-in work as well. They are frequently used for thoracic endovascular repair of the aorta (TEVAR), repair of abdominal aortic aneurysm (AAA), and transcatheter aortic valve replacement (TAVR).

These rooms would seem to be perfect for some trauma cases as well. Some injuries require a mix of interventional work and open surgery. Think complex pelvic fractures and extremity vascular injuries.

But before you go rushing off to the hybrid room with the next patient you think might benefit from it, consider these issues:

  • You must first secure access to the hybrid room. Just because you want it doesn’t mean you can get it. This room was probably built with other services in mind. You must work with them closely to set up rules and priorities. Consider questions like, can a trauma case bump an elective one?
  • Decide what specific cases can be done in the room. Don’t waste it on procedures that can be done in any old OR. Ideally, it is for multi-team cases and must take advantage of the radiographic capabilities of the hybrid room. If it doesn’t, it should be done in any other room of appropriate size.
  • Check your hardware. Make sure that anything you might attach to the hybrid table actually will attach to it. Frequently, the side rails are missing and the table thickness is different than a standard OR table. Check all of your retractor systems for compatibility. If your neurosurgeons use a skull clamp like a Mayfield, make sure it will attach to the table. If they do not, look for adapters to make it possible. Don’t discover this on your first trip to the room.
  • Watch for hypothermia! These are big rooms, and are difficult to heat up uniformly. In addition, the electronics in the room may be heat sensitive, so you may not be able to raise the temperature to the levels you are accustomed. Place heating systems under and around the patient as much as possible, warm everything that goes into them, and monitor their temp closely.
  • Treat the equipment with respect.  This stuff is delicate, and must be used by other surgeons for sensitive procedures. Don’t break it!

Related posts:

Source: The Trauma Professionals’s Blog

How To Remember Those “Classes of Hemorrhage”

The Advanced Trauma Life Support course lists “classes of hemorrhage”, and various other sources list a similar classification for shock. I’ve not been able to pinpoint where these concepts came from, exactly. But I am sure of one thing: you will be tested on it at some point in your lifetime.

Here’s the table used by the ATLS course:

classes_of_shock

The question you will always be asked is:

What class of hemorrhage (or what % of blood volume loss) is the first to demonstrate systolic hypotension?

This is important because prehospital providers and those in the ED typically rely on systolic blood pressure to figure out if their patient is in trouble.

The answer is Class III, or 30-40%. But how do you remember the damn percentages?

multiscore-maxi1

It’s easy! The numbers are all tennis scores. Here’s how to remember them:

Class I up to 15% Love – 15
Class II 15-30% 15 – 30
Class III 30-40 30 – 40
Class IV >40% Game (almost) over!

Bottom line: Never miss that question again!

Source: The Trauma Professionals’s Blog

Pan Scanning for Elderly Falls?

The last abstract for the Clinical Congress of the American College of Surgeons that I will review deals with doing a so-called “pan-scan” for ground level falls. Apparently, patients at this center have been pan-scanned for years, and they wanted to determine if it was appropriate.

This was a retrospective trauma registry review of 9 years worth of ground level falls. Patients were divided into young (18-54 years) and old (55+ years) groups. They were included in the study if they received a pan-scan.

Here are the factoids:

  • Hospital admission rates (95%) and ICU admission rates (48%) were the same for young and old
  • ISS was a little higher in the older group (9 vs 12)
  • Here are the incidence and type of injuries detected:
Young (n=328) Old (n=257)
TBI 35% 40%
C-spine 2% 2%
Blunt Cereb-vasc inj * 20% 31%
Pneumothorax 14% 15%
Abdominal injury 4% 2%
Mortality * 3% 11%

 * = statistically significant

Bottom line: There is an ongoing argument, still, regarding pan-scan vs selective scanning. The pan-scanners argue that the increased risk (much of which is delayed or intangible) is worth the extra information. This study shows that the authors did not find much difference in injury diagnosis in young vs elderly patients, with the exception of blunt cerebrovascular injury.

Most elderly patients who fall sustain injuries to the head, spine (all of it), extremities and hips. The torso is largely spared, with the exception of ribs. In my opinion, chest CT is only for identification of aortic injury, which just can’t happen from falling over. Or even down stairs. And solid organ injury is also rare in this group.

Although the future risk from radiation in an elderly patient is probably low, the risk from the IV contrast needed to see the aorta or solid organs is significant in this group. And keep in mind the dangers of screening for a low probability diagnosis. You may find something that prompts invasive and potentially more dangerous investigations of something that may never have caused a problem!

I recommend selective scanning of the head and cervical spine (if not clinically clearable), and selective conventional imaging of any other suspicious areas. If additional detail of the thoracic and/or lumbar spine are needed, specific spine CT imaging should be used without contrast.

Related posts:

Reference: Pan-scanning for ground level falls in the elderly: really? ACS Surgical Forum, trauma abstracts, 2016.

Source: The Trauma Professionals’s Blog

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