Here are three recorded war games cases presented with me as the student by Joe Sills, a medical student who worked with me. It allows you to hear what I do with unknowns, and how to work through the data to create plans. Thanks. JY
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A discussion of the tension between cost containment and the need to prevent unexpected negative outcomes. Some patients do not have a sign on them saying “I’m sick, intubate me and take me to the ICU”. Sometimes the signs are much more subtle, and will not be appreciated without a high degree of suspicion and paranoia.
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Check out a discussion on surgical education I had with Dr. Chris Porter, founder of the great website Onsurg.com.
Jul 20
A discussion of abdominal trauma and its various presentations and treatments. Song from the album I made with Tom Jolly. Thanks for listening. JY
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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.
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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
Jun 15
Very interesting paper in New England Journal of Medicine (NEJM 2009;361:1368-75, Variation in hospital mortality associated with inpatient surgery) that hospitals have widely variable mortality rates, but surprisingly very similar complication rates. What seems to differentiate great hospitals from good ones, is the ability to rescue patients from complications, not preventing complications.
This is a very important finding, because rescue, in hospitals, is often neglected. We assume that the same nurses and staff that perform routine daily medical care, can immediately transition into providers that can handle the rapidly changing variables present in a patient who is declining or crashing. Often saving a patient with a major complication requires aggressive resuscitation, thorough and rapid search for a cause, and immediate intervention. Another problem is that these patients often look “sick” but dont look like they are “dying”. By the time they look like they are dying, it is often too late to effectively intervene.
Also you could gather 10 patients with sepsis, and they will all have different symptoms, vital signs, and lab data. It takes an experienced caregiver, with a very healthy paranoia, to intervene correctly in these situations. Another maxim of rescue (in hospital and out) is the acceptance of over-reaction. I have talked about this before in that the fire-ems community accept a rather large percentage of calls where they “over respond” based on the eventual facts of the situation. Hospitals are only now learning the importance of over-reaction, and the fact that if you are going to catch the 5 patients who are dying from a complication, you may need to vigorously intervene on the 20 patients who just “look like something is wrong”. Waiting until those 5 patients declare themselves as “really sick” will likely eliminate your opportunity to save all of them. Thus, over-reaction will save lives.
When you’re doing an infectious investigation, and we’re all guilty of not doing this, you really do need to look everywhere. The kinds of patients that we get in the unit continue to be febrile, continue to have white counts, we don’t know why. You need to look at every IV site, you need to do a rectal, make sure they don’t have peri-rectal, turn them to make sure they don’t have an infected decubitus. I can forgive anybody that the first time through you get a chest x-ray, they’ve got an obvious pneumonia, productive sputum, it’s not a big deal if you didn’t strip them and look at everything, but once you’ve had someone who’s been treated for 3 to 4 days with a presumptive diagnosis, they’re still sick, they’re still febrile, they’ve had a big drop in their white count (and remember, a big drop in the white count is consistent with sepsis not with getting better). You need to say, I’d strip them, look all over their skin, I’d look at their old sites. Look at the IV sites, do a rectal, make sure they don’t have peri-rectal, look at them, look at their back and make sure they don’t have a decubitus
This podcast follows the latest blog entry. How do you get the most out of scored evaluation and training scenarios. This training and testing mechanism has become the most important tool in most organizations for teaching and evaluating students and new employees. Using this teaching tool optimally is incredibly important to both the person being evaluated, and to the organization. I present my thoughts on how to get the most out of the process.
Also have parts of an original song I wrote and performed at the beginning and end. Please tell people who you think may enjoy the podcasts and site, up to 18,000 downloads and want to reach as many people as we can.
Thanks.
JY
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