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All posts for the month July, 2012

Friends,

Ive found it hard to design podcasts to appeal to everyone in and out of the hospital, so I started other website Fire-EmsBrainTraining.com. The site is up right now.

I’m transferring some of the EMS focused material to that site, and hope to get a lot of help from my fire and ems friends for guest postings and podcasts.

The link is on the blog roll to the right.

I opened up the ACS news and saw my chief resident’s smiling face. He presented a paper demonstrating that procedural volume does not correlate with mortality, thus destroying a popular quality measure. In it he says that finding out what really does effect quality is the “billion dollar” question.

A year ago, after a great deal of frustration with the quality measures that were being propagated, I wrote the document I have attached. I sent it to various powers that be nationally, and naturally didn’t hear anything. I invite you to read it and think about it. Evidence is rare and weak for anything related to examination of processes, and I hate to put another unsubstantiated model for patient safety out there, but you can read it and decide.

Here is the link:

AnRealisticAssessmentSystemforHospitalSafetyandQuality doc

JY

One very disturbing trend in the country in the past few years has been the idea that unless you perform simulation in a $8million center on a Medisim HPS, you are not really doing anything. This is crazy.

The literature shows that high tech simulation is more effective for technical tasks (laparoscopy), but low tech simulation is still useful. Many of the studies focus on student attitudes toward the simulation. If you asked someone what was more enjoyable and useful to you – an afternoon off service at the sim center, or a vigorous verbal war game in the ICU or at the bedside, what would you choose?

When you try to think of how to simulate the tragedy in Aurora, are we going to wait until we can set up a multi-agency disaster drill (which you might do twice a year at most), or is it better to get 10 players around a table and say “OK we just got word from the ECC there is an active shooter at the theater, you are the administrator on call and you are the ED attending, tell me what you are going to do first, second and third?” Then you add variants as the scenario plays out (“your OR calls down and tells you no more patients can come up for at least 60 minutes, you just got word there are two patients coming in a medic unit hypotensive with GSWs to the abdomen and the only other hospital said they are not taking any more patients,  what are you going to do?)

We need to do both and stop this idea that only high cost, high tech simulation is useful, it is not supported by evidence, and even if low tech was not as useful, it is a lot easier to do and schedule, and is a lot cheaper. What we need is structure to the low tech simulation and a way to evaluate performance. I have tried to provide some information on how to do that in the war games manual. Please take a look at it. Here is the link:

http://www.amazon.com/Clinical-Brain-Training-How-To-ebook/dp/B007BSPHRK

If you really dont have $1 let me know and I’ll send you a free copy.

JY

 

I’ve participated in probably a few dozen disaster drills and mock disasters, as well as commanded the hospital side of five MCIs with up to 20 patients over the years, and after listening to the tapes of the fire response from the Aurora incident Thursday, I don’t believe we as a medical system in the US are adequately prepared to handle those incidents effectively. It sounds like the FD and the hospitals in that area did a fantastic job, but from listening to the tape, it wasn’t until the Battalion Chief arrived at the theater that any semblance of ICS was instituted. Fire depts have a great system to insure that trained Chief officers are available 24/7, hospitals, not so much. For a center like ours, which is the only trauma center for at least 50 miles in all directions, we would have to handle almost all the red priority patients. The trauma surgeon on call is likely not trained in ICS, and may be a year or two out of fellowship. I have confidence the processes for an MCI will work, but that may not necessarily handle this sort of incident effectively.

With an active shooter, the most important hospital resources are OR’s, surgeons, and OR teams (anesthesiologists and nurses/techs). We would also need blood, ICU nurses, and a lot of other help to take care of everyone else in the hospital while we’re dealing with this. Most disaster plans treat an MD as an MD, for this type of situation, general/thoracic/and vascular surgeons and anesthesiologists are the highest resource. After that, we cant do anything without an OR and and OR team. While in most disasters, EM physicians and ED staff are the most important, they cant take a patient to the OR and stop bleeding. Every trauma center (and hospital in a populous area) needs to learn more about and create an active shooter MCI protocol that specifically addresses these key resources.

For those readers (especially those overseas) who have been through these types of incidents, or people who have created these types of protocols, please add your comments so we can learn from your experience. Our hearts go out to all the victims and families affected by this tragedy.

JY

In the era of cost containment, developing explanations for patient’s condition that minimize or ignore contrary data is attractive and very dangerous. This podcast outlines the issue, and presents some solutions to combat minimization. Thanks, JY.

I’ve taken care of lots of patients with life threatening injuries and surgical problems. When I look back and try to figure out what was the key factor in survival, it is keeping the problems one-dimensional.

What I mean is that it is rare to find any single system problem (outside of the heart and the brain) that is immediately and uniformally fatal. What happens is that you get a major abdominal problem, you dont watch kidney function close enough (or react quick enough to changes) and you lose the kidneys, then your fluid balance goes to hell and the patient gets intubated and has worsening vent settings, and so on, and so on.

If I can give one bit of advice from 18 years of taking care of these patients, even if you miss something big and have to do an emergency operation in the middle of the night that should have been done the previous day, you can get the patient over it if you jump on protecting their other organ systems with two feet. That is not the time to diurese them if you are unsure of their fluid status, it is not the time to start narrow spectrum antibiotics, and it is not the time to hold of on intubating them because you think the ABG is not giving you an accurate picture.

 

The way to get these patients through these episodes is to be over aggressive in protecting the function of the remaining systems. Once you lose the kidneys,  go into ARDS, and become coagulapathic, things get much more complicated. Also, remember, do what you neeed to do to protect their remaining organ systems, and this means holding off on procedures and tests that are not central to the problem at hand. If a patient is looking septic, that is not the time to undergo a 5 hour plastics facial reconstruction, unless you think that is central to the infectious problem. Same with ortho procedures and all others. Remember, operations that do not correct your central problem are a physiologic hit to the patient, and it may be one hit too many. These are decisions for the most experienced member of the team, and that should be the attending.

This is a discussion of the algorithms and tactical decisions when you have a trauma patient with a positive FAST. In the podcast, we had a quasistable patient with a positive FAST and a severe pelvic fracture, head injury, and pulmonary contusion. How do you decide what decisions the FAST triggers and what should your reasoning be?

First, remember trauma patients have blood in their belly all the time and the vast majority of them do not go to the OR. In my practice, we admit around 75 blunt spleen injuries, and 90 blunt liver injuries a year, and only around 10% go to the operating immediately for hypotension. The remainder are treated with a non-operative protocol of bedrest and re-evaluation. Of those, around 93% are successfully managed without surgery. So just having fluid in your abdomen, which is what a positive FAST says, does not mean you need to get a laparotomy.

So who does or does not get a laparotomy? Keep in mind we are only talking blunt trauma, penetrating has different algorithms.

An unstable, or recurrently unstable patient with a positive FAST gets a laparotomy, in my opinion. These are patients who present with a SBP<90 who does not increase their BP with fluids (at least 2 liters) and/or blood. If that patient has a positive FAST, then you go to the OR hyperurgently (meaning right now). If that patient has focal neurologic signs, then you need to do your best to rule out a intracranial mass lesion with CT, but that needs to be an attending decision, and the patient needs to be alive (you have more options with a living patient). I once took a patient during residency in this situation to get a head CT with a clamp on their aorta. My attending was not amused. Having a clamp on your aorta is pretty much the definition of unstable, and they cant stop for a head CT. A recurrently unstable patient (or more commonly known as a transient responder) needs surgery. However, in that case, a head CT may be possible with vigorous blood resuscitation, but again, the patient needs to be alive enough to transport.

In this case, we have a quaistable patient (I know many of you have not heard these terms, and we may be the only ones using them). This is a patient with a stable BP, who requires ongoing resuscitation, but whose BP continues to rise and their perfusion improves. To us, this means the patient has bled considerably, but may have stopped, or has a bleed that is worsening when the BP exceeds a certain level. Thus, their perfusion never gets back to normal, but is not worsening. These patients usually have time for CT, but need to be watched like a hawk. We also feel better having big central access and an arterial line. If the patient begins to get unstable, they get pulled off the CT table and go to the OR.

The pelvic fracture adds a big wrinkle. We feel laparotomies are not good for a patient bleeding from pelvic fractures (the Denver group obviously disagrees). This could be a long argument, but I’ll skip it. read the literature and form your own opinion. In this case, you are quasistable with a head injury so you go to CT. You find hemoperitoneum, a minor liver injury, and a major LC3 pelvic fracture with an arterial blush. Angio can kill two birds with one stone in these patients, if you have good access to IR, and good interventionalists (which we have). They can control the pelvic bleeding, squirt theliver and take care of any arterial injuries there, and even squirt the aorta if you didnt have time for a CTA.

Once, again the Chief resident and the Attending should be no more than 20 meters from these patients at any time, and should always keep a close eye on the monitor. If they begin to crash, you may need a new plan. Remember, never let someone bleed to death when you could stop the bleeding in the OR, but also remember, some bleeding can only realistically be controlled by IR.

Add your opinions, nicely.

JY

 

This week I go through a major ED trauma resuscitation from start to finish. The patient has head, chest, pelvis, and extremity injuries with hypotension. I stress what you should be thinking as each new piece of data comes in, and what your rols should be as team leader, or supervisor/coach. I will also expand on some of the points on the website. Thanks, JY