Interaction between Surg and EM during Traumas

[pepgh]

I'm an intern at a program with a bit of graduated responsibility. I've started to go to more traumas and what I see is concerning to me. I drank the cool-aid during interview season and early on in the year but now I'm starting to see how things really are.

Surgery dominates traumas. The fellow runs it, surgery residents do all the procedures except airway and ATLS protocol is very loosely followed.
My medical school had a very strong gen surg program and ATLS was followed to the tee, procedures rotated between EM and surg residents on even and odd days, and the trauma attendings generally had more respect for the EM attendings.

I realize that when it comes down to it, trauma is a surgical disease and we aren't the ones that are ultimately going to take the patient to the OR or care for them on the floor but I feel that my education is suffering. We've had problems with some of our residents not having the required number of procedures before graduation. Do you guys have any thoughts? Should I say something and hope that our leadership goes to bat for us?

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[filhodeinferno]

I'm an intern at a program with a bit of graduated responsibility. I've started to go to more traumas and what I see is concerning to me. I drank the cool-aid during interview season and early on in the year but now I'm starting to see how things really are.

Surgery dominates traumas. The fellow runs it, surgery residents do all the procedures except airway and ATLS protocol is very loosely followed.
My medical school had a very strong gen surg program and ATLS was followed to the tee, procedures rotated between EM and surg residents on even and odd days, and the trauma attendings generally had more respect for the EM attendings.

I realize that when it comes down to it, trauma is a surgical disease and we aren't the ones that are ultimately going to take the patient to the OR or care for them on the floor but I feel that my education is suffering. We've had problems with some of our residents not having the required number of procedures before graduation. Do you guys have any thoughts? Should I say something and hope that our leadership goes to bat for us?

Tough situation. Sounds like you'd have quite the uphill battle fighting against the culture and status quo of your facility. Perhaps once you're a more senior resident and more comfortable in your skin you'll be able to slip yourself into the midst of the trauma procedures. One of my criteria in ranking programs where the ED seemed more politically powerful in the hospital so that they could hold their own in turf battles like this.

 

[alpinism]

I'm an intern at a program with a bit of graduated responsibility. I've started to go to more traumas and what I see is concerning to me. I drank the cool-aid during interview season and early on in the year but now I'm starting to see how things really are.

Surgery dominates traumas. The fellow runs it, surgery residents do all the procedures except airway and ATLS protocol is very loosely followed.
My medical school had a very strong gen surg program and ATLS was followed to the tee, procedures rotated between EM and surg residents on even and odd days, and the trauma attendings generally had more respect for the EM attendings.

I realize that when it comes down to it, trauma is a surgical disease and we aren't the ones that are ultimately going to take the patient to the OR or care for them on the floor but I feel that my education is suffering. We've had problems with some of our residents not having the required number of procedures before graduation. Do you guys have any thoughts? Should I say something and hope that our leadership goes to bat for us?

Sigh. No its not.

Having surgery come down for every trauma is as ridiculous and wasteful as having cardiology see every chest pain or infectious disease see every fever.

See below:

"INTRODUCTION
In 2008, the American College of Surgeons (ACS) abandoned its traditional assertion that “trauma is a surgical disease,”1 tacitly acknowledging the largely nonoperative nature of modern trauma care.2-4 At my large tertiary medical center, for example, the prevalence of emergency operative intervention by a trauma surgeon is just 3.0% of adult trauma team activations and just 0.35% of pediatric activations,5 with these frequencies decreasing to 1.2% and 0.09%, respectively, if one excludes penetrating mechanisms. For blunt trauma at my hospital, emergency operation by a trauma surgeon averages once every 7 weeks for adults and less than once every 3 years for children.5 Comparable numbers have been reported elsewhere.6-9"

Ann Emerg Med. 2011 Aug;58(2):172-177.e1. doi: 10.1016/j.annemergmed.2011.04.030. Epub 2011 Jun 12.
Trauma is occasionally a surgical disease: how can we best predict when?
Green SM.

 

[BoardingDoc]

Surgery dominates traumas. The fellow runs it, surgery residents do all the procedures except airway and ATLS protocol is very loosely followed.

What? How the hell are you expected to do it as an attending? Just stand around and hope that a trauma surgeon shows up in your community trauma bay? This is something that should absolutely be brought up with your leadership. At the very least they need to justify how your current system is not leaving you unprepared for a significant part of your role as an ED attending.

 

[gman33]

Talk to your PD.
Something needs to be done to help with your education.
If you are not doing anything in the trauma currently, I wouldn't even go. Your time would be better served by seeing another patient.

 

[HooliganSnail]

This is a big problem.

I am at a community hospital where there is not a large surgery presence, and EM runs the traumas almost entirely.

I don't say this to brag, but to point out that most ED's are like mine. When you are an attending, surgery is NOT coming in anytime soon, so if the patient needs a chest tube, you need to do it correctly, efficiently, and quickly. This means you need to have enough experience during residency.

You need to talk with your PD and chief residents about your concerns. Chances are they are aware of the problem as it is. By going through your PD, you can (hopefully) get some interdepartmental cooperation with GS to get some more trauma experience. Surgeons generally hate trauma anyways, so if the ED can handle more of it, they are appreciative.

Do it sooner, rather than later.

 

[Hamhock]

I wonder where all the folks are who claim trauma is not important/cookbook/ATLS/etc.

Medical students: do you want to be in the OP's position?

HH

 

[BoardingDoc]

I wonder where all the folks are who claim trauma is not important/cookbook/ATLS/etc.

Medical students: do you want to be in the OP's position?

HH

Trauma is largely cookbook. That doesn't mean that OP shouldn't be familiar with the recipes before going out as an attending.

 

[Arcan57]

Trauma is largely cookbook. That doesn't mean that OP shouldn't be familiar with the recipes before going out as an attending.

Atls is all sorts of useful for single provider settings dealing with major trauma. It's significantly less useful for the resource rich environment of the tertiary care Trauma center.

 

[Hercules]

I wonder where all the folks are who claim trauma is not important/cookbook/ATLS/etc.

Medical students: do you want to be in the OP's position?

HH

I still claim that trauma training is less important and predominantly cookbook. The reason isn't because trauma itself isn't important. It's because you don't need a ton of exposure to it and almost all programs provide a more than adequate exposure. As a result being deficient in your trauma training in residency is an extremely rare occurrence. It sounds like the OP could possibly be in an outlier program like that which is a tough spot to be in.

There's a Peds exposure thread going on right now, and I would say there are far more programs that give a potentially inadequate Peds exposure than there are programs with an inadequate trauma exposure. Despite that there are always more questions about trauma training in residencies than there are about Peds.

 

[gro2001]

I still claim that trauma training is less important and predominantly cookbook. The reason isn't because trauma itself isn't important. It's because you don't need a ton of exposure to it and almost all programs provide a more than adequate exposure. As a result being deficient in your trauma training in residency is an extremely rare occurrence. It sounds like the OP could possibly be in an outlier program like that which is a tough spot to be in.

There's a Peds exposure thread going on right now, and I would say there are far more programs that give a potentially inadequate Peds exposure than there are programs with an inadequate trauma exposure. Despite that there are always more questions about trauma training in residencies than there are about Peds.

I would add that it is also much easier to make up a real or perceived deficit in trauma education by doing an away rotation than it is to make up a deficit in your skills with complex medical patients or kids. If you do 1 month at some place like Shock Trauma, in that one month you could see almost as much trauma as the median EM resident sees in their whole residency. There is no equivalent experience for medically complex adults or sick kids. There is no 'level 0' sepsis center. That kind of skill is much more granular and requires a longitudinal approach.

 

[deleted109597]

There is no 'level 0' sepsis center.

I disagree. At our main site trauma/first trimester vag bleed/homeless free sandwiches of excellence, this isn't common. At the community site, where 50-80% of the patients that don't see the midlevels are admitted, a fair chunk are sepsis/septic shock. All you have to do is find the hospital where all the old people go.

 

[The White Coat Investor]

A brief comment from the real world, not necessarily about trauma.

I just got back downstairs from the ICU. The only other doctor in the hospital, the hospitalist, was having trouble intubating an ICU patient. I stuck the glidescope in, and there was bloody foamy sputum pouring out of the airway. I couldn't see crap. A few minutes of what I now consider routine airway management skills and the 24 year old post-partum mother was now stabilized. The hospitalist was profuse in his "thank yous." He then had to run to another hospital to round on other patients (yes, our hospitalists cover multiple hospitals) and asked if I wasn't too busy if I'd throw in a line for him. Now, I bill for these lines and I had nothing going on in the ED, so I said sure. My nurse brought up my US and I stuck in a line.

There was no surgeon, anesthesiologist, intensivist, etc anywhere else. It's just me. I'm thankful to have had excellent residency training such that procedures that scare and intimidate other physicians are quite routine for me.

Also, a counterpoint on the "trauma is cookbook" thing. I disagree somewhat. There is a fair amount of complexity as to how various traumatic injuries are treated. The role of the EP in a level 1 trauma center is pretty cookbook, but community trauma is different at my level 3 center. When the patient goes upstairs, no other doctor has seen him but me and nobody will see him for 6-12 hours. It's not just the ABCs and they whisk away with a team of residents or midlevels. I'm often surprised at how little I know about the first week of management of many traumatic injuries. Not sure where I could have picked that up but it would be useful information.

 

[Old_Mil]

Surgery dominates traumas. The fellow runs it, surgery residents do all the procedures except airway and ATLS protocol is very loosely followed.

I realize that when it comes down to it, trauma is a surgical disease...

Trauma is only a "surgical disease" in the sort of large multi speciality, resident rich, tertiary care centers you are training in.

At 1am on a Friday night in a 40,000 visit ER where the ambulance is 5 minutes out and the on call surgeon is 15-20 guess what kind of disease it is?

You can call a trauma alert and you will get an RT, a phelbotomist, and a rad tech. If you are lucky enough not to be single coverage doc #2 will probably come in and do a fast / pneumodart / whatever while you tube the patient.

I feel that my education is suffering.

That is because it is...and if this situation has been allowed to develop in the trauma bay, don't expect that it will be corrected on your ICU months.

We've had problems with some of our residents not having the required number of procedures before graduation.

You will make those procedures up in sim lab or on cadavers. Also keep your eyes open for the coding / dead medical patient where the performance of a trauma procedure isn't unreasonable. Talk to your attending before you do a pericardiocentisis on a dead medical code to get the OK or a finger thoracostomy on a dead patient with pulmonary disease though.

Should I say something and hope that our leadership goes to bat for us?

Whatever you do, keep your mouth shut...unless you want to end up scrambling for an intern slot at a Family Medicine residency in North Dakota next year. Leadership doesn't want to hear it.

You have identified the problem. How you address it: you need to find one or two surgical residents you like and attach yourself to them like a remora to a shark when they are around. Scrounge up the procedural crumbs they spill. Assist in any way possible.

There are entire courses that do a great job transmitting this sort of knowledge in the commercial world - Ron Walls Airway Course, Critical Points, the list goes on. Go to a couple while you are still in residency as a supplement.

I will even throw in this link from the Jedi Master in case you haven't discovered it yet.

http://blog.ercast.org/trauma-arrest/

http://emcrit.org/podcasts/traumatic-arrest/

Similar, the first also includes information on the proper use of VL. The second focuses more on trauma arrest specifically.

Don't worry too much about ED thoracotomy. Odds are you are going to end up working someplace where this it is impractical unless you go into academics.

Good luck.

I certainly would never ask you to reveal where you are training or even the region. That would be very unwise.

But to satisfy my own curiousity is a CMG (EMcare/Team/etc) partially funding your program? You can answer in a PM if you wish.

For all you med students, a CMG isn't going to get involved in a residency out of the goodness of their hearts. It may have something to do that it costs them half as much to have a resident help attendings move meat as an experienced NP/PA. Just saying that finding out details like this may be in your best interest before you make a rank order list.

 

[HooliganSnail]

Traumatic Arrest is a procedure gold mine. Almost all procedures are indicated. B/L decompression follow by B/L Chest Tubes, Central Line (cordis), IO, Pericardiocentesis, Intubation, hell do a Cric ( I personally never call a code without a definite airway).

In most facilities if the patient has no pulses following trauma, the trauma team does not get activated because it is a substantial allocation of resources that are not likely to be utilized ( OR goes on alert, CT clears the table, Anesthesia gets called in). At our shop, trauma gets pissed if they get paged for an arrest, so it is all ER.

 

[deleted547339]

Traumatic Arrest is a procedure gold mine. Almost all procedures are indicated. B/L decompression follow by B/L Chest Tubes, Central Line (cordis), IO, Pericardiocentesis, Intubation, hell do a Cric ( I personally never call a code without a definite airway).

In most facilities if the patient has no pulses following trauma, the trauma team does not get activated because it is a substantial allocation of resources that are not likely to be utilized ( OR goes on alert, CT clears the table, Anesthesia gets called in). At our shop, trauma gets pissed if they get paged for an arrest, so it is all ER.

If you're doing a pericardiocentesis on a trauma, you're doing it wrong.

 

[HooliganSnail]

If you're doing a pericardiocentesis on a trauma, you're doing it wrong.

How?

You think they should all get cracked?

You think they should all just get the U/S?

 

[deleted547339]

How?

You think they should all get cracked?

You think they should all just get the U/S?

Yes and yes.

 

[Rendar5]

Agreed. If you're going to go after fluid in the heart in a traumatic arrest, go after it in a way that can salvage the patient. And if it's not a salvageable patient, you should not be doing any of those procedures in the first place outside of maybe an intubation
The patient died, they did not donate their body to medical science.

Sorry, ma'am. I know your daughters dead, but we needed practice so we put some extra holes in her body. I'm sure you don't mind.

 

[DrDrummer]

In most facilities if the patient has no pulses following trauma, the trauma team does not get activated because it is a substantial allocation of resources that are not likely to be utilized ( OR goes on alert, CT clears the table, Anesthesia gets called in). At our shop, trauma gets pissed if they get paged for an arrest, so it is all ER.

Is that really the policy in most places? Makes total sense to me. Definitely not the policy where I train though, which for patients I think ends up being a wash and for EM residents definitely cuts down on this as a source of practice opportunities.

 

[HooliganSnail]

Yes and yes.

I am all about cracking a chest, but I am a firm believer of doing it in situations where the evidence backs you up. Penetrating trauma with recent signs of life, and a downtime of less than 5 minutes. Even then it has a low success rate.

Taking the time to put an ultrasound on the heart to see if an effusion is there in the middle of a trauma (which is often hectic) is a waste of time. They have already arrested. Diagnosis time is long past. Stick a needle under the xiphoid and see if you can aspirate some blood. In a true tamponade, even removing as little as 10 cc blood can get ROSC.

So to smack back at you because you're being pompous about it, If you are NOT doing a pericardiocentesis in a traumatic arrest, then you are doing it wrong.

 

[HooliganSnail]

Agreed. If you're going to go after fluid in the heart in a traumatic arrest, go after it in a way that can salvage the patient. And if it's not a salvageable patient, you should not be doing any of those procedures in the first place outside of maybe an intubation
The patient died, they did not donate their body to medical science.

Sorry, ma'am. I know your daughters dead, but we needed practice so we put some extra holes in her body. I'm sure you don't mind.

How can you decide someone isn't salvageable if you havn't tried! Those procedures are done to eliminate the salvagable causes of the arrest!

Once you have eliminated any of those, then it's time to call it. There is no point in doing chest compressions for 30 minutes.

Every traumatic arrest patient should have B/L decompressions.

Every traumatic arrest patient should have a pericardiocentesis. Now one could argue that if you couldn't aspirate any blood in a pericardiocentesis, threw an U/S on there and saw a huge effusion, then thoracotomy would be indicated regardless of the cause of the arrest, but there is nothing wrong with just presuming it could be there and going after it blindly with a needle.

Every traumatic arrest patient needs a definite airway, if you can't get one, then you need to do a cric.

Every traumatic arrest needs 2 large bore IV's wide open to try to fill the heart up.

Also I need an accucheck, cause who the hell knows if they crashed their car because their sugar was 10.

Only after those (reversible) causes have been eliminated, can you reasonably call the code.

"Sorry Ma'am, without even attempting to save your daughter, I just decided it was hopeless and called it quits. Hope she didn't have a tamponade....."

It wasn't my intention to insinuate that the OP should just do procedures on patients for no reason, but in a traumatic arrest, every one of those procedures is INDICATED for good reason, and if you aren't doing them, then you are really lying when you tell the family that you did everything you could.

 

[deleted547339]

I am all about cracking a chest, but I am a firm believer of doing it in situations where the evidence backs you up. Penetrating trauma with recent signs of life, and a downtime of less than 5 minutes. Even then it has a low success rate.

Taking the time to put an ultrasound on the heart to see if an effusion is there in the middle of a trauma (which is often hectic) is a waste of time. They have already arrested. Diagnosis time is long past. Stick a needle under the xiphoid and see if you can aspirate some blood. In a true tamponade, even removing as little as 10 cc blood can get ROSC.

So to smack back at you because you're being pompous about it, If you are NOT doing a pericardiocentesis in a traumatic arrest, then you are doing it wrong.

Respectfully disagree. An echo takes about 3 seconds. And if you see cardiac standstill, you're done. Definitely a time-effective maneuver. If you don't see an effusion, it's not the heart and sticking a needle into the patient isn't indicated.

I see very little, if any, indication for a traumatic pericardiocentesis.

 

[Arcan57]

How can you decide someone isn't salvageable if you havn't tried! Those procedures are done to eliminate the salvagable causes of the arrest!

Once you have eliminated any of those, then it's time to call it. There is no point in doing chest compressions for 30 minutes.

Every traumatic arrest patient should have B/L decompressions.

Every traumatic arrest patient should have a pericardiocentesis. Now one could argue that if you couldn't aspirate any blood in a pericardiocentesis, threw an U/S on there and saw a huge effusion, then thoracotomy would be indicated regardless of the cause of the arrest, but there is nothing wrong with just presuming it could be there and going after it blindly with a needle.

Every traumatic arrest patient needs a definite airway, if you can't get one, then you need to do a cric.

Every traumatic arrest needs 2 large bore IV's wide open to try to fill the heart up.

Also I need an accucheck, cause who the hell knows if they crashed their car because their sugar was 10.

Only after those (reversible) causes have been eliminated, can you reasonably call the code.

"Sorry Ma'am, without even attempting to save your daughter, I just decided it was hopeless and called it quits. Hope she didn't have a tamponade....."

It wasn't my intention to insinuate that the OP should just do procedures on patients for no reason, but in a traumatic arrest, every one of those procedures is INDICATED for good reason, and if you aren't doing them, then you are really lying when you tell the family that you did everything you could.

You do understand that these procedures were developed prior to the widespread use of U/S?

 

[HooliganSnail]

Respectfully disagree. An echo takes about 3 seconds. And if you see cardiac standstill, you're done. Definitely a time-effective maneuver. If you don't see an effusion, it's not the heart and sticking a needle into the patient isn't indicated.

I see very little, if any, indication for a traumatic pericardiocentesis.

Touche.

 

[HooliganSnail]

You do understand that these procedures were developed prior to the widespread use of U/S?

No, the procedures were developed because they fix reversible causes of cardiac arrest. NOT doing the procedures (and having a generation of doctors who are uncomfortable with them) has developed because of the widespread use of U/S. For the seasoned attendings out there, who feel comfortable with the procedure should they need to do it, they may forgo them en lieu of their sonographic skills, but every ER doctor needs to be ABLE to do them. Not allowing your residents to do them because of the ultrasound is a bad idea.

Technology is awesome. I love the ultrasound, and I use it all the time. In fact, I've started not even listening to both lungs during the traumas (very error-prone, plus my stethoscope gets all bloody), I just do a quick ultrasound of both sides.

I also believe in knowing the old school ways. Everyone of us should be able to do blind central lines, direct intubation, and blind pericardiocentesis. Technology breaks sometimes.

But in the arrested trauma patient, I believe every one of them needs an airway and three needle marks. And I really don't think that is "violating" anybody.

 

[gutonc]

I was hoping someone would post a review of the new program at Mogadishu State.

 

[gro2001]

How can you decide someone isn't salvageable if you havn't tried! Those procedures are done to eliminate the salvagable causes of the arrest!

Once you have eliminated any of those, then it's time to call it. There is no point in doing chest compressions for 30 minutes.

Every traumatic arrest patient should have B/L decompressions.

Every traumatic arrest patient should have a pericardiocentesis. Now one could argue that if you couldn't aspirate any blood in a pericardiocentesis, threw an U/S on there and saw a huge effusion, then thoracotomy would be indicated regardless of the cause of the arrest, but there is nothing wrong with just presuming it could be there and going after it blindly with a needle.

Every traumatic arrest patient needs a definite airway, if you can't get one, then you need to do a cric.

Every traumatic arrest needs 2 large bore IV's wide open to try to fill the heart up.

Also I need an accucheck, cause who the hell knows if they crashed their car because their sugar was 10.

Only after those (reversible) causes have been eliminated, can you reasonably call the code.

"Sorry Ma'am, without even attempting to save your daughter, I just decided it was hopeless and called it quits. Hope she didn't have a tamponade....."

It wasn't my intention to insinuate that the OP should just do procedures on patients for no reason, but in a traumatic arrest, every one of those procedures is INDICATED for good reason, and if you aren't doing them, then you are really lying when you tell the family that you did everything you could.

You can't have it both ways.

If you believe that the emergent thoracotomy is a life saving procedure, then you should believe it must be mastered by all EM residents. The emergent thoracotomy in a traumatic arrest in an extremely complex procedure. As with all complex procedures, it requires repetition ad nauseum under a variety of circumstances to really master. Think about how many attempts it took you to genuinely MASTER some other procedures ER residents train to perform. Most residents do not train at programs that would allow them to get anywhere within an order or magnitude of the number necessary for mastery of that procedure if it was only performed on those patients meeting strict indications. Before anyone jumps in with a comment about how at THEIR residency they had done 100 thoracotomies by end of intern year, I get it, you trained at an amazing program. But think of the AVERAGE EM resident. The average EM resident only having done a few thoracotomies on patients it was indicated on will not maximize his chances of being able to save that one 19 year old stabbing victim of his career that may be the only salvageable-by-thoracotomy patient of his career.

So which is it? If the ED thoracotomy a life saving procedure that must be mastered by all ER residents? Or is it outside the scope of our practice? If it's the former, you should advocate performing it on as many of the unsalvageable patients as possible so it may one day save someone. If it's the latter, you shouldn't be doing the on anyone.

 

[alpinism]

How can you decide someone isn't salvageable if you havn't tried! Those procedures are done to eliminate the salvagable causes of the arrest!

Once you have eliminated any of those, then it's time to call it. There is no point in doing chest compressions for 30 minutes.

Every traumatic arrest patient should have B/L decompressions.

Every traumatic arrest patient should have a pericardiocentesis. Now one could argue that if you couldn't aspirate any blood in a pericardiocentesis, threw an U/S on there and saw a huge effusion, then thoracotomy would be indicated regardless of the cause of the arrest, but there is nothing wrong with just presuming it could be there and going after it blindly with a needle.

Every traumatic arrest patient needs a definite airway, if you can't get one, then you need to do a cric.

Every traumatic arrest needs 2 large bore IV's wide open to try to fill the heart up.

Also I need an accucheck, cause who the hell knows if they crashed their car because their sugar was 10.

Only after those (reversible) causes have been eliminated, can you reasonably call the code.

"Sorry Ma'am, without even attempting to save your daughter, I just decided it was hopeless and called it quits. Hope she didn't have a tamponade....."

It wasn't my intention to insinuate that the OP should just do procedures on patients for no reason, but in a traumatic arrest, every one of those procedures is INDICATED for good reason, and if you aren't doing them, then you are really lying when you tell the family that you did everything you could.

This gets discussed on the traumalist all the time.

See below.

Hey, just to continue in the ED pericardiocentiesis v ED thoracotomy debate: the following is lifted from Trauma.org, an international website for trauma surgeons.

Eric Frykberg (ERF) is one of the most recognized names in the trauma community. Sounds like a move away from the use of ED p'centesis and window is underway.

a message dated 11/27/2002 7:00:36 PM Eastern Standard Time, [email protected] writes:

This is just not true, as anyone with experience at cardiac injuries will attest--I have yet to see it work at all for this purpose, and many iatrogenic--a couple at least fatal--injuries the patient just does not need. Whenever you open the pericardium of someone with traumatic tamponade, it is full of CLOT--the best explanation of why a needle decompression does not work. And no--it is not worth the try, either--much too risky--what these patients need is an immmediate thoracotomy with opening of the sac, evacuation of the clot and a finger on the hole--THEN you can wait for someone who can close the chest to arrive. Actually, this is a system problem, if you must wait at all for someone to arrive with no one to immediately help. Don't fool yourself into thinking this kind of mucking around does anything real for the patient
ERF

 

[Arcan57]

No, the procedures were developed because they fix reversible causes of cardiac arrest. NOT doing the procedures (and having a generation of doctors who are uncomfortable with them) has developed because of the widespread use of U/S. For the seasoned attendings out there, who feel comfortable with the procedure should they need to do it, they may forgo them en lieu of their sonographic skills, but every ER doctor needs to be ABLE to do them. Not allowing your residents to do them because of the ultrasound is a bad idea.

Technology is awesome. I love the ultrasound, and I use it all the time. In fact, I've started not even listening to both lungs during the traumas (very error-prone, plus my stethoscope gets all bloody), I just do a quick ultrasound of both sides.

I also believe in knowing the old school ways. Everyone of us should be able to do blind central lines, direct intubation, and blind pericardiocentesis. Technology breaks sometimes.

But in the arrested trauma patient, I believe every one of them needs an airway and three needle marks. And I really don't think that is "violating" anybody.

Excellent evasion of my question. I trained in a very busy trauma center in the era when FAST was being universally adopted (and misapplied) but when the sliding lung sign was something only U/S trained fellows had heard of. I ran hundreds of major traumas. I've seen two ED thoracotomies and one in the OR. Outside of a handful of large urban trauma centers, EM programs have never had enough numbers to produce competence. Its comforting to appeal to an idyllic past where every program produced flawless proceduralists who cracked chests, drilled burr holes, and criched no neck patients with magnificent outcomes. But that's not how things were and technology has improved outcomes not worsened them. The mortality for a resuscitative thoracotomy without surgical backup is so close to 100% that injury to providers is more likely than a good outcome for the patient. Doing a quick U/S to determine viability and need for resuscitative procedures is a valid strategy, especially for providers that have high technical profiency in U/S but low reps otherwise.

 

[WilcoWorld]

If I didn't know SDN so well I'd be surprised there's this much disagreement here.

"You're doing it wrong" can often be more profitably stated "I'd do it differently, because..."

How many think it's unreasonable/dangerous/unethical to use an ultrasound probe to see if a pulseless trauma patient can be salvaged?

How many think it's unreasonable to use a few large needles to do the same thing?

As long as nobody here is advocating cracking the chests of patients with signs of lividity I think all can make a reasonable argument.

 

[badasshairday]

I think it is BS to say trauma is cookbook. You need experience in facets of medicine before you get comfortable. Remember placing your first line? Remember intubating your first patient? Remember running your first code? It is all cookbook, but you need to do it many times to get comfortable and deal with patients who don't like to follow recipes.

 

[Janders]

Has anyone here seen or have direct knowledge of a trauma arrest, due to cardiac tamponade / hemopericardium, which was revived via blind pericardiocentesis?

Purely opinion, but I suspect odds of causing injury > odds of helping patient, just as the quoted trauma surgeon above mentions. Granted we are already in a situation with odds of death >99%

Personally, I'm going to slap a probe at the xyphoid very early in this patient's course-- (1) to eval for tamponade but also (2) to confirm pulselessness / cardiac standstill (its not always terribly obvious in a 300lb trauma patient...) Lots of ways to skin a cat, but I'd chose this one. Granted I'm in a non-trauma center, often single-covered as far as ED physician, with the odds of a general surgeon being around the "help" with a trauma arrest being very low. We do still get trauma arrests, at least monthly in the summer. Modify ATLS a little bit when you are solo-covered (i.e. if their airway looks generally patent and EMS is bagging them easily, I'm going to vent bilateral chests before I tie myself up intubating them...).

 

[Old_Mil]

I am all about cracking a chest, but I am a firm believer of doing it in situations where the evidence backs you up. Penetrating trauma with recent signs of life, and a downtime of less than 5 minutes. Even then it has a low success rate.

For community level 3 and below facilities my recommendation is only a penetrating trauma with witnessed loss of pulses in the ED with a surgeon in house. Don't turn down one way streets.

 

[HooliganSnail]

For community level 3 and below facilities my recommendation is only a penetrating trauma with witnessed loss of pulses in the ED with a surgeon in house. Don't turn down one way streets.

Absolutely agree.

I left that part out, but it's probably the most important exclusion for thoracotomy. If there is no CT surgeon to come in to take the patient to the OR, Do Not crack a chest

 

[HooliganSnail]

You can't have it both ways.

If you believe that the emergent thoracotomy is a life saving procedure, then you should believe it must be mastered by all EM residents. The emergent thoracotomy in a traumatic arrest in an extremely complex procedure. As with all complex procedures, it requires repetition ad nauseum under a variety of circumstances to really master. Think about how many attempts it took you to genuinely MASTER some other procedures ER residents train to perform. Most residents do not train at programs that would allow them to get anywhere within an order or magnitude of the number necessary for mastery of that procedure if it was only performed on those patients meeting strict indications. Before anyone jumps in with a comment about how at THEIR residency they had done 100 thoracotomies by end of intern year, I get it, you trained at an amazing program. But think of the AVERAGE EM resident. The average EM resident only having done a few thoracotomies on patients it was indicated on will not maximize his chances of being able to save that one 19 year old stabbing victim of his career that may be the only salvageable-by-thoracotomy patient of his career.

So which is it? If the ED thoracotomy a life saving procedure that must be mastered by all ER residents? Or is it outside the scope of our practice? If it's the former, you should advocate performing it on as many of the unsalvageable patients as possible so it may one day save someone. If it's the latter, you shouldn't be doing the on anyone.

The emergent thoracotomy has been controversial since it was first done over a 100 years ago.

How I feel about them changes from day to day, case to case. I know that seems wishy washy, but it is true. Even in the best circumstances, the outcomes are very poor.

I believe the thoracotomy is within the scope of practice of an EM doctor, the same way that an emergent drainage of priapism, a peri-mortem C section, and a lateral canthotomy are.

I do not think that it should be a required procedure of all EM residents, and currently the ACGME agrees with me, as it is not on their list of required procedures to be logged. Neither is the canthotomy (which no one argues is well within our scope of practice), and peri-mortem C-section (also not argued about, but debatably even more dire). At the right time, and if you're all that is around, then you are the one who has to do it. That is the nature of ED medicine

I am not having it "both ways", I think that the thoracotomy should be done if it is indicated, just like the lateral canth, and the peri-mortem C-section. We should not be doing them in the ED just for ****s and giggles if there isn't an indication.

I think the best solution is to require a CT surgery rotation during ER residency to get experience with a thoracotomy in general.

 

[Apollyon]

If there is no CT surgeon to come in to take the patient to the OR, Do Not crack a chest

My division chief in residency said she did that while moonlighting. Sure, the aorta is cross-clamped. Yeah, and?

I have said that the cracked chest, if successful, is the only EM procedure that does not stand on its own. Then again, of course, I am likely wrong.

 

[HooliganSnail]

Excellent evasion of my question. I trained in a very busy trauma center in the era when FAST was being universally adopted (and misapplied) but when the sliding lung sign was something only U/S trained fellows had heard of. I ran hundreds of major traumas. I've seen two ED thoracotomies and one in the OR. Outside of a handful of large urban trauma centers, EM programs have never had enough numbers to produce competence. Its comforting to appeal to an idyllic past where every program produced flawless proceduralists who cracked chests, drilled burr holes, and criched no neck patients with magnificent outcomes. But that's not how things were and technology has improved outcomes not worsened them. The mortality for a resuscitative thoracotomy without surgical backup is so close to 100% that injury to providers is more likely than a good outcome for the patient. Doing a quick U/S to determine viability and need for resuscitative procedures is a valid strategy, especially for providers that have high technical profiency in U/S but low reps otherwise.

Yeah but nowhere in my ( and by "my" I mean, "pretty much standard of care") trauma algorithm does it include a thoracotomy for all, it just says, get an airway, eliminate tension pneuno, cardiac tamponade, attempt to volume resuscitate, and check a blood sugar. If all of those are eliminated, call the code. Can you really say that those things are unnecessary?

I know thoracotomy is a **** show. I know the outcomes are terrible. I believe they should be done if and only if they are indicated, which is a penetrating arrest with signs of life In The Department. Otherwise, don't crack the chest. It seems to me that we are in agreement about that.

If you want to eliminate the pneumo and tamponade with an ultrasound....Great! However chest tubes and pericardiocentesis are required procedures by the ACGME, and they are just as effective at eliminating that reversible cause of death. Cric's are also required by the ACMGE, and equally as important and lifesaving. I personally never call a code without definite airway, and that means ET tube or a Cric. Combitube, King tube, LMA....none of those are definite airways.

That whole rant of mine started because someone commented that I was basically being a cowboy procedure junky who wants to mutilate bodies and has no respect for the dead because I think its worthwhile to do a pericardiocentesis, which frankly I found to be poor form.

 

[EM/CC_23]

For community level 3 and below facilities my recommendation is only a penetrating trauma with witnessed loss of pulses in the ED with a surgeon in house. Don't turn down one way streets.

Let me preface this by saying, I'm very interested in this, but I'm only a 4th year med student with no experience ever performing a thoracotomy:

I've heard some recent excitement about prehospital thoracotomy in Europe for penetrating trauma with <10 minutes of cardiac arrest. There is an interesting case series (N =71) in J Trauma 2011 (Pubmed ID: 21131854) about prehospital thoracotomy for penetrating thoracic trauma (NOTE: all from stab wounds, no ballistic trauma) being performed by EM or anesthesia flight physicians from the Royal London Hospital (when they arrived to the scene <10 minutes after cardiac arrest, or witnessed the arrest themselves). The flight physician arrived to the scene, performed thoracotomy if the patient met the above criteria, and then transported the patient rapidly to the Royal London Hospital (trauma center, not the nearest hospital). They don't say how long transport times were, unfortunately.

There were 13/71 survivors (18% survival), of which 2 had poor neurologic outcome, and 1 had "impaired" neurologic outcome. All patients with good neurologic outcome (N=10, 14%) either had witnessed arrest by the flight physician, or the flight physician arrived <5 min after arrest. All 13 of the survivors had tamponade from either RV (N=12) or aortic (N=1) stab wounds.

They go on to mention that there was a series in Japan with prehospital thoracotomy after blunt trauma with no survivors, so they limit their performance of prehospital thoracotomy to penetrating trauma only. They also say they've done this in the setting of penetrating thoracic GSWs, with no survivors, so they think it only seems to be a viable option for stab wounds.

When performed on a carefully selected population of patients who are stabbed in the chest and have a cardiac arrest within 5 minutes of presenting to the ED, could thoracotomy still be a useful therapy in a non-trauma center (or freestanding ED for that matter) if the patient were able to be transported rapidly to a facility where a surgeon and operating room were waiting for the patient's arrival? Could such a patient be transported by your local EMS/flight transport team, or would you (or another physician) have to leave your ED to take the patient to the trauma center with the transport team (and would this logistical issue make it impossible to transport the patient safely)?

 

[alpinism]

ED thoracotomy outcomes highly depend on the mechanism of injury.

While blunt trauma outcomes are terrible (about 1-3% survival), penetrating trauma outcomes are anything but terrible and are actually very good (relatively speaking compared to CPR outcomes etc...). Temple has a reported 33% survival rate following stab wounds (http://www.ncbi.nlm.nih.gov/pubmed/18653499) while Emory has a 20% survival rate (http://www.ncbi.nlm.nih.gov/pubmed/3789290).

 

[Old_Mil]

(An aside: canthotomy is a pretty important procedure...isolated facial trauma is much more common than the rare set of circumstances that lead to a thoracotomy and if you get to it in time you can make a real difference)

 

[TheBlueBlazer]

Doing a blind pericardiocentesis on a trauma arrest patient is idiotic. I can tell you in no more than 5 seconds if there is tamponade. If there is tamponade physiology there is likely either a large amount of clot or a substantial ongoing bleed. In either of these cases, what the patient needs is a thoracotomy if you think the are salvageable, and that very salvagability probably depends on what you see on the subxiphoid view.

Spending time with CT surgery is somewhat useful for learning the anatomy, but you are mostly going to be doing so via a sternotomy. The view is quite different.

Routine trauma is pretty damn cookbook. Severe trauma is also pretty cookbook. It's the stuff in the middle that we need to have an understanding of - what you're not going to necessarily see on imaging that needs to be considered, what needs a trauma center vs able to be observed/managed locally, and what you need to be able to temporize when it falls apart.

I would definitely talk to your PD about this, though I imagine they have an idea because of people's low procedure quotas, but the more people that mention it to them, the harder they can push.

 

[pepgh]

I ended up not saying anything. I get the sense that our PD gets annoyed by people who complain. Its obvious that it sucks, they know it, we know it. Another crappy thing is that when admitting a patient to medicine, the conversation is attending to attending. No resident involvement. This was a newly implemented rule by the hospital.

 

[Psai]

I ended up not saying anything. I get the sense that our PD gets annoyed by people who complain. Its obvious that it sucks, they know it, we know it. Another crappy thing is that when admitting a patient to medicine, the conversation is attending to attending. No resident involvement. This was a newly implemented rule by the hospital.

What was the rationale for that?

 

[filhodeinferno]

What was the rationale for that?

Seems bad for education, but I'd love never having to call report to the floor.

 

[WilcoWorld]

I ended up not saying anything. I get the sense that our PD gets annoyed by people who complain. Its obvious that it sucks, they know it, we know it. Another crappy thing is that when admitting a patient to medicine, the conversation is attending to attending. No resident involvement. This was a newly implemented rule by the hospital.

I would argue that being able to get a patient admitted to Medicine takes more experience to master and is more important in 95% of EP's jobs than running traumas.

I was willing to overlook your trauma woes earlier, because I think that "only doing airways" is almost ideal for an EM resident. You get to see the full spectrum of trauma patients, you get to see how these patients respond to XYZ resuscitation strategies, AND you get all the airways but you don't have to sew up all the damn lacerations or birddog CT to get the scans done.

However, if you're not learning how to sell an admit you're missing out on one of EM's most important "procedures". That is a real problem.

 

[gman33]

I'm more concerned about the admissions.
That is a huge part of your future job.

Advocating for your education can be tricky.
Maybe have a resident meeting and come up with issues and solutions.

The Chiefs can bring it up with admin.

 

[Old_Mil]

I ended up not saying anything. I get the sense that our PD gets annoyed by people who complain. Its obvious that it sucks, they know it, we know it. Another crappy thing is that when admitting a patient to medicine, the conversation is attending to attending. No resident involvement. This was a newly implemented rule by the hospital.

Make sure you listen to your attending sell the admits to medicine. This is an important skill.