The Seventh Law of Trauma

Your patient is at their healthiest as they roll in through the emergency department door

Yes, major trauma patients are sick, but they are going to get sicker over the next few hours to days. No matter how bad they look now, they will tolerate more at the time you first see them than they will tomorrow.

Too often, we look at them and delay because “they are too sick to operate.” This is usually not the case.

Bottom line: Move quickly, get surgical clearances done promptly, and perform all interventions (especially major surgery) early before your trauma patient gets really sick!

Other Laws of Trauma:

Source: The Trauma Professionals’s Blog

Cognitive Bias – Don’t You Hate It When They Do That?

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Source: http://chainsawsuit.com/comic/2014/09/16/on-research/

I sat in on a committee meeting once where the management of a particular clinical problem was being vigorously discussed. One of the participants pulled out his smartphone, did a quick search, and said, “Aha! This article shows that my opinion is correct!”

This approach is wrong on so many levels, it’s almost laughable. But it illustrates a real weakness that all human beings have: susceptibility to cognitive bias. 

Scientists have identified somewhere between 150 and 200 different types of cognitive bias, and trying to sort them out will literally make your head spin. For a quick and enlightening read, I recommend reading the article below. It sifts through the mess and lumps them into four understandable categories.

Bottom line: We are all capable of warping what we read, hear, and see to fit our own vortex of pre-existing beliefs. It’s very important to recognize the possibility of bias when you are seeking information so that you can do everything to minimize its impact. If you can’t or won’t do that, then you’ll end up being that know-it-all guy with the smartphone.

Related post:

Source: The Trauma Professionals’s Blog

Trauma Morning Report – A Best Practice?

Hospital medicine in general, and inpatient trauma care specifically, is now characterized by a series of handoffs. These occur between physicians, trainees, nurses, and a host of other trauma professionals. Many trauma centers have implemented a “morning report” type of handoff, which formalizes part of the process and frequently adds a teaching component.

The group at the University of Arkansas studied the impact of implementing a morning report process on length of stay and care planning. Prior to the study, residents handed off care post-call to other residents without attending surgeon involvement. The morning report process added the presence of the post-call surgeon, and the trauma and emergency general surgery attendings coming on duty. Advanced practice nurses collected information on care plan changes.

Here are the factoids:

  • Problem: There is mention of a survey with 79% response rate detailing 219 trauma admissions during the 90 day study period. This is not explained anywhere else in the abstract, so it is not clear if the data presented represents all admissions.
  • 69% of patients were admitted to a ward bed, and 31% to ICU
  • Change to the care plan occurred during morning report in 20% of patients
  • The most common care plan changes were: addition of a procedure in 45%, medication change in 34% (typically pain management)
  • Mean hospital length of stay decreased from 10 to 6 days (!)

Bottom line: This small, prospective study quantifies a few of the benefits of a formal “morning report” process. The fact that just a little bit of trauma attending oversight decreased length of stay by a whopping 4 days suggests that the residents really needed the increased supervision. Discharge planning is a multidisciplinary activity, and should be a major part of the rounding routine as well.

Formalizing the handoff process is always a good thing. Yes, it takes time and planning, but as this and other studies have shown, it is well worth the effort!

Related posts:

Reference: Morning report decreases length of stay in trauma patients by changing care plans in 20% of patients. AAST 2016, Poster 124.

Source: The Trauma Professionals’s Blog

ED Use of CT – Everyone Does It Differently

There is tremendous variability in ordering imaging in trauma patients. To some degree, this is due to the dearth of standards pertaining to radiographic imaging, at least in trauma. And when standards do exist, trauma professionals are not very good at adhering to them. We’d rather do it our way. Or the way we were trained to do it.

The group at Jamaica Hospital in Queens, NY quantified some of those differences, studying ordering patterns of trauma surgeons (TS), emergency physicians (EP), and surgery chief residents (CR). Unfortunately, they then tried to draw some interesting conclusions, which I’ll discuss at the end.

They reviewed all blunt trauma activations over a 6 month period at their urban trauma center. At the end of each trauma activation, each of the three physician groups wrote imaging orders, but only the trauma surgeons’ were submitted. Missed injuries were defined as any that would not have been found based on each provider group’s orders. Extremity injuries, and those found on physical exam or plain imaging were excluded.

Here are the factoids:

  • The authors do not state how many patients they saw in this period, but by extrapolation it appears to be about 250
  • Trauma surgeons ordered significantly more studies (1,012) than the EPs (882) or CRs (884)
  • This resulted in essentially a “pan-scan” in 78%, 64%, and 69%, respectively
  • Radiation exposure was said to be the same for all groups (18 vs 13 vs 15 mSv) [I’m having a hard time buying this]
  • But cost was higher in the trauma surgeon group ($344 vs $267 vs $292) [Huh? Is this only the electric bill for the CT scanner? Very low, IMHO]
  • And the trauma surgeons had a missed injury rate of only 1%, vs 11% for EPs and 7% for CRs [Wow!]

Bottom line: Sorry, I just can’t believe these results. There are a lot of things left unsaid in this poster. What were all these missed injuries? What magical CT scan that only the trauma surgeons ordered actually picked them up? And probably most importantly, were they clinically significant? A small hematoma somewhere doesn’t make a difference (see the “tree falls in a forest” post below).

It looks to me like the authors wanted to justify their use of pan-scan, and push their emergency physicians to follow suit. Unfortunately, this is a poster presentation, meaning that there will be limited opportunity to question the authors about the specifics.

The debate regarding pan-scan vs selective imaging is an active one. The evidence is definitely not in yet. While we sort it out, the best path is to develop a reasonable imaging practice guideline based on the literature, where available. Some areas such as head and cervical spine CT have been worked out fairly well. Then fill in the blanks and encourage all trauma professionals in your hospital to follow them. There is great value in adhering to good guidelines, even when there are blanks in our knowledge.

Related posts:

Reference: Variability in computed tomography imaging of trauma patients among emergency department physicians and trauma surgeons with respect to missed injuries, radiation exposure and cost. AAST 2016, Poster #75.

Source: The Trauma Professionals’s Blog

Managing Mild TBI Without A Neurosurgeon

TBI is a very common injury, and neurosurgeons are relatively rare resources for trauma centers. That mismatch can create significant problems for trauma programs. Reflexively, we consult neurosurgeons for a wide variety of neurotrauma, ranging from the very severe to the extremely mild.

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Can we intelligently and selectively utilize the skills of our neurosurgeons, and not jeopardize patient safety? Surgeons at Baystate Medical Center in Springfield MA reviewed their own experience managing mild TBI.

They defined a mild TBI as one with patient GCS of 13-15. However, their study included only patients with “GCS>14”, which I presume means all patients with GCS=15 (unless this is a typo). They allowed patients with normal GCS and intoxication, epidural (EDH) or subdural hematoma (SDH)<4mm, small subarachnoid hemorrhage (SAH), and non-displaced skull fracture (Fx). Any patient taking any type of anticoagulant or anti-platelet drug was excluded. They looked at need for neurosurgical consultation or intervention, readmission, and 30 day mortality.

This prospective study spanned 13 months. This lower volume center admitted 1341 patients, of which 77 were included in the study. Average age was 55, and average ISS was 16. A total of 97% presented for a followup visit (!).

Here are the factoids:

  • 47% had SAH, 43% SDH, 16% intraparenchymal hemorrhage (not mentioned in inclusion criteria), 14% Fx, and no EDH
  • Only one patient required neurosurgery consult, and none required intervention
  • There were no mortalities
  • Most (62%) were admitted to a ward bed, and the average length of stay for all patients was 3 days
  • Cost savings was estimated at about $16,000

Bottom line: Yes there is no magic in getting a neurosurgical consult for most mild TBI. The study is small, but telling. A carefully crafted practice guideline can dramatically decrease the (over)use of our neurosurgeons, saving both time and money.

In reviewing their guideline, I would recommend shaving even one more point off the GCS (>14), but stipulating that any central subarachnoid hemorrhage require consultation because of the possibility of an aneurysm being the culprit.

Check out the guideline in use at my hospital below. Also, look at the first related post, which is similar in idea to this one, but you can see the difference in management by surgeons vs neurosurgeons.

Related posts:

Reference: Mild traumatic brain injuries can be safely managed without neurosurgical consultation: the end of a neurosurgical “nonsult”? AAST 2016, Poster 51.

Source: The Trauma Professionals’s Blog

Early Mobilization In Solid Organ Injury

Most trauma centers have some kind of practice guideline for managing solid organ injury. Unfortunately, the specifics at each center are all over the map. Here are a few common questions:

  • Should you keep the patient NPO?
  • How often should Hgb/Hct be repeated?
  • Should they be at bed rest?
  • What are their activity restrictions after they go home?

spleen-lac

As for activity, some earlier studies have shown that early ambulation is safe. The group at Hahnemann University Hospital in Philadelphia tried to determine if early mobilization would decrease time in ICU and/or the hospital, or increase complications.

Until 2011, their trauma service kept all patients with solid organ injury at bed rest for 3 days(!). They modified this routine to allow ambulation the following morning for Grade 1 and 2 injuries, and after 24 hours for Grade 3 and above, or those with hemoperitoneum. They examined their experience for 4 years prior (PRE) and 4 years after (POST) this change. They excluded patients with penetrating injury, or other significant injuries that would impact the length of stay.

Here are the factoids:

  • 300 solid organ injury patients were identified in the PRE period, and all but 89 were excluded
  • 251 were identified in the POST period, and all but 99 were excluded
  • Hospital length of stay was significantly shorter (5.9 vs 3.7 days) after implementation of the new guideline
  • ICU length of stay also decreased significantly, from 4.6 to 1.8 days
  • The authors extrapolated a cost savings of about $40K for the ICU stay, and $10K for the ward stay, per patient
  • There was one treatment failure in each group

Bottom line: It’s about time we recognized what a waste of time these restrictions are! Unfortunately, the study groups became very small after exclusions, but apparently the statistics were still valid. But still, it continues to become clear that there is no magic in keeping someone starving in their bed for any period of time.

At my hospital, we adopted a practice guideline very similar to this one way back in 2004 (download it below). Hospital lengths of stay dropped to about 1.5 days for low grade injury, and to about 2.5 days for high grade.

And earlier this year, we eliminated the NPO and bed rest restrictions altogether! How many patients actually fail and end up going urgently to the OR? So why starve them all? And normal activity started immediately is no different than activity started a few hours or days later.

Don’t starve or hobble your patients, adults or children!

Related posts:

Reference: Early mobilization of patients with non-operative liver and spleen injuries is safe and cost effective. AAST 2016, Poster #5.

Source: The Trauma Professionals’s Blog

September Trauma MedEd Is Here! Topic: Field Amputation

Welcome to the current newsletter. This one tells you everything you always wanted to know about field amputation (and dismemberment). Here’s the scoop on what’s inside:

  • Indications
  • Who can perform it?
  • What about logistics
  • Equipment
  • Blow by blow about the procedure itself
  • Supplemental resources, include policies, equipment list, and bibliography

Just so you know, subscribers received this issue at the beginning of the month. If you want to subscribe and get it before everyone else, just click here.

Got a suggested theme for later issues? Just let me know what you’d like to read about by replying to this email!

To download the current issue, just click here! You can also enter this web URL directly into your browser: http://bit.ly/TME201609  (All caps! Case is important.)

Thanks for reading!

Source: The Trauma Professionals’s Blog

Predicting VTE Risk In Children

There’s a lot of debate about if and at what age injured children develop significant risk for venous thromboembolism (VTE). In the adult world, it’s a little more clear cut, and nearly every patient gets some type of prophylactic device or drug. Kids, we’re not so certain about at all.

The Children’s Hospital of Wisconsin tried to tease out these factors to develop and implement a practice guideline for pediatric VTE prophylaxis. They prospectively reviewed over 4000 pediatric patients admitted over a 6 year period.

It looks like the guideline was developed using some or all of this data, then tested using regression models to determine which factors were significant. The guideline was then tweaked and a final model implemented.

Here are the factoids:

  • 588 of the patients (14%) were admitted to the ICU, and 199 of these were identified as high risk by the guidelines
  • Median age was 10 (this is always important in these studies)
  • VTE occurred in 4% of the ICU patients, and 10% of the high risk ones
  • Significant risk factors included presence of central venous catheter, use of inotropes, immobilization, and GCS < 9

Bottom line: This abstract confuses me. How were the guidelines developed? What were they, exactly? And the results seem to pertain to the ICU patients only. What about the non-ICU kids? The abstract just can’t convey enough information to do the study justice. Hopefully, the oral presentation will explain all.

I prefer a very nice analysis done at the Oregon Health Science University in Portland. I wrote about this study earlier this year. The authors developed a very useful calculator that includes most of the risk factors in this model, and a few more. Input the specific risks, and out comes a nice score. The only issue is, what is the score threshold to begin prophylaxis and monitoring? Much more practical (and understandable) than this abstract. Check it out at the link below.

Related post:

References:

  1. Evaluation of guidelines for injured children at high risk for VTE: a prospective observational study. AAST 2016, Paper 68.
  2. A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients. JAMA Surg 151(1):50-57, 2016.

Source: The Trauma Professionals’s Blog

Confusion At The Trauma Professional’s Blog?

Many readers may have noticed that the blog site has looked different for the past week. The good news is that I’ve migrated all my content (and more) to a standalone website, TheTraumaPro.com.

But the bad news was that all of the search engines only know of the original site, regionstraumapro.com, the original blog hosted on Tumblr. So a lot of people ended up being directed to an old post (on the new site) and not knowing why or how they got there. Confusing! Furthermore, links to related posts on the Tumblr site took readers to the same old random post on the new site. Even more confusing!

In order to stem the confusion while the search engines catch up, I’ve decided to run both sites in parallel. All posts will be cross-posted to both sites simultaneously. The Twitter notification will link to the post on the new site, but it will still be on Tumblr as well.

Please check out all the extra content on the new site at:

TheTraumaPro.com

but just be aware that searches for content will probably direct you to Tumblr at:

regionstraumapro.com

Thanks for reading, whichever one you choose!

Michael

Source: The Trauma Professionals’s Blog

Cervical Spine MRI After Negative CT

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There are multiple ways to clear a cervical spine! Most centers use a combination of clinical decision tools and CT scan in adults. The gold standard tie breaker, warranted or not, seems to be MRI. This tool is only used in select cases where conventional imaging is in doubt, or the clinical exam is puzzling.

Some centers clear based on CT only as long as imaging is indicated. Some use MRI in cases where patients continue to complain of midline neck pain or tenderness after negative CT. A multi-center trial encompassing 8 Level I and II centers prospectively performed MRI on patients who could not be clinically evaluated, or had persistent midline cervical pain after normal CT.

A total of 767 patients were seen over a 30 month period. Besides looking at the usual data points, the authors were interested in new diagnoses and changes in management based on the MRI results.

Here are the factoids:

  • Neck pain and inability to evaluate occurred with equal frequency, about 45%; the remaining 10% had both
  • 23% of MRIs were abnormal, with 17% ligament injury, 4% swelling, 1% disk injury, and 1% dural hematomas.
  • Patients with normal and abnormal MRI had neurologic anomalies about equally (15-19%). [Why are these patients included? Were they initially not evaluable?]
  • The cervical collar was removed in 88% of patients with normal MRI (??), and in 13% with abnormal MRI
  • After (presumably) positive MRI, 14 (2%) underwent spine surgery; 8 of these had neurologic signs or symptoms

Bottom line: I’m a bit confused. If the authors were really trying to figure out the rate of abnormal MRI after negative CT, they should have excluded the patients with known neurologic findings. These patients should nearly always have an abnormal MRI. And why did they not take the collar off of the 12% of patients with both normal CT and MRI??

Hopefully, details in the presentation next week will help explain all this. I suspect that the study will show that there are cases where CT is normal but MRI is not. The abstract does not clearly describe how many of these are clinically significant.

I admit, I’m not very comfortable clearing the cervical spine in a patient with negative CT (even if read by a neuroradiologist) and obvious midline neck pain/tenderness. I hope this study helps clarify this issue. We shall see…

Reference: Cervical spine MRI in patients with negative CT: a prospective, multicenter study of the research consortium of New England centers for trauma (ReCONECT). AAST 2016, Paper 61.

Source: The Trauma Professionals’s Blog

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