serious clinical policy question for current residents

[unk_fxn]

Are any EM residencies training EM residents to do invasive neurotrauma procedures such as ventricular drains, burrholes, and ICP monitoring?

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[Seaglass]

The question is why would you want to?

 

[roja]

*sigh*

I again agree with seaglass.


Why on earth would you want to do this. EM's are not neurosurgeons.

 

[peksi]

ICP monitoring/Ventriculostomy

Actually I inserted 3 ICP monitors as a PGY 2 covering the SSICU/NeuroICU, with one of our nerurosurgeons at my side (Umm back in 1997!). This was merely because i was there, as was the oppertunity. We've only had 1-2 (2003-4) other residents do this with the neurosurgeons in the ED for progressive SAH pt's who are at the end of the Hunt and Hess scale. This is not common by any means, but the oppertunity came up and the neurosurgeon was willing to walk the resident through it. Most Level 1 trauma ED's have some of this equip in the ED, but for the consultants. I would suggest that no one really gage an EM program by the number of ventrics/ICP bolts get placed by EM cause for most places it will be ZERO....or US now maybe it is 0.0001%.

Burr Holes....when I was an EM US Fellow i nearly had to do this on a patient (kit open patient preped) until i found out that the Neuro Surgeon was "IN HOUSE" and then I convinced him with my South Philly verbage to get the the ED!....for those of you on the list from Christ/Advocate (Just ask Riz, or Pizzano!). Moral...you really hope you do not need to do this procedure, this one makes the trauma surgeons nervous as well.

So conclusion...in general these are not the perview of EM in todays era. ABEM lists them, but they generally are relegated to war stories, just like mine. I'd be more focused on the Ultrasound education...but that's really my bias!!!

Paul

 

[unk_fxn]

The question is why would you want to?

EM's are not neurosurgeons.

Well, why would want to put in a chest tube or intubate someone? EM isnt surgery, its not anesthesia either, right?

What if the patient is sick and there is no one else to do it?

Image you are working in a rural hospital with no neurosurgical staff (we lost ours when they left the state due to the PLI crisis here). The helicopters aren't flying because of weather. Ground transport to the refferal center is going to be 3-4 hours. Medical management has been optimized, and the patient is still getting worse.

Obviously, this is not a metric for residency education, but do you just let them herniate?

Is the procedure really much more complicated/invasive than a thoracotomy?

 

[Seaglass]

There are a lot of procedures that might be lifesaving in the ED in RARE circumstances that we are not qualified to do. Chest tubes and intubation are fairly common procedures that are often useful. I suppose if I were in that situation I would get a neurosurgeon on the phone and a surgeon at the bedside and do the burr, but I don't expect my residency program to provide me with that experience (thank God!). Perimortem C-section anyone?

 

[Sessamoid]

I did a couple ventrics during my medical school neurosurg rotations, and maybe 2 or 3 during residency with a neurosurgeon standing there. I also did one in private practice also with a neurosurgeon standing with me. Not what I would generally call a standard EM procedure though.

 

[roja]

crack a chest with now CT surgeon available?


Sure your patient has a penetrating chest wound and lost vitals in your ed, but your in the boonies and don't have a surgeon. Yup, your patient is getting worse.

Do you still crack the chest?

No, its contra-indicated.


Maybe, maybe maybe, I would consider a burr hole, but if you have the capabilites of monitoring ICP you probably aren't stuck out where you have nothing but a drill and a crashing patient.


The analogy to chest tubes and intubations is completely inaccurate. One because they are common occurances in the ED, and two because we can manage them afterwards.

 

[waterski232002]

crack a chest with now CT surgeon available?


Sure your patient has a penetrating chest wound and lost vitals in your ed, but your in the boonies and don't have a surgeon. Yup, your patient is getting worse.

Do you still crack the chest?

No, its contra-indicated.

Contra-indictated???

Why would you NOT crack the chest? The patient is already dead (no vitals), so he/she can't get any worse.

 

[unk_fxn]

Contra-indictated???

Why would you NOT crack the chest? The patient is already dead (no vitals), so he/she can't get any worse.

I would agree... one of the places I did a sub-I the attending spoke of a few patients where a moonlighting senior in EBF (outlaying rural center) did a code - thoracotomy, revived the patient, dressed the chest wound, and then flew the patient to the refferal center. He said he knew of at least one that made it to a functional discharge.

 

[anonymousEM]

we just talked about burr holes in confrence last week. the "consensus" by the ACEP clinical policy makers is that they are not teaching the procedure in their residencies and that unless you are "skilled" in burr holes you shouldn't be doing them because you can often make an epidural worse than the bleed you started with...that being said we proceded to go through the slides on how to do it, but I've never seen one done in our ctr.

 

[roja]

Why wouldn't you?

If you want to argue the morals of cracking a chest on a patient that is already dead so that you can learn or practice the procedure, that is a different discussion. (and possibly one that has some merit, but is still a different discussion)


Yes, cracking a chest with no CT surgeon is contra indicated. If you don't believe it, ask around. (I did the same from all the attendings working today, and the resounding answer [including two lilcon grads] was its an absolute contra indication.) And this arguement makes sense.

Lets just go with a hypothetical: you crack the chest, you have no CT surgeon (and maybe, just maybe you could get transport) but lets say, no transport. What are you going to do? Open heart surgery in the ED?


Notice that even the burr holes, etc that were done, were done with the appropriate consult. The job of the EDP is not to perform every life saving procedure. (we don't cath MI's, we don't do appendectomies and we don't resect bowels...) A profecient EDP doesn't think that s/he can do everything. They know their limits and when to call the appropriate consult.

(also, multiple online sites mention that only an experienced MD should be doing ED an ED thoracotomy. Not sure how many makes 'experienced' but it seems like a valid statement....)

 

[waterski232002]

I don't think anyone would argue with you that EM physicians are not going to do "open-heart surgery" in the ED! I don't know if others were confused by your diction in the original post, but I assumed you meant that there was a CT surgeon in the area, but just not immediately available.

However, even if there was no CT surgeon available, if you could arrange transport to a facility that did have one, why would you not attempt to do a thoracotomy and stabilize the patient for possible transport? The patient is coding in front of you with a penetrating chest injury and the only way you will be able to immediately discern what the problem is and acutely manage it would be to attempt to treat the cause of the code (tension pneumo, hemothorax, tamponade, hemorrhage). Just because you open up someone's chest does NOT mean you need to be able to do Bypass--you just need to regain stable vitals in the patient until they can receive more definitive care. Let's say it's a ruptured subclavian... you don't need to reanastamosis the vessel--just tie it off! If you can tie off the source of the bleeding and control it, then that is most important b/c that is the immediate life threatening injury. Better to lose the arm than lose your life.

I would hope that if I was shot in the chest in rural america that I would be given every opportunity to be treated (CT surgeon or not).... Furthermore, I think you need to use your judgement on a case-by-case basis... Guidelines are just that--"guidelines". We are not robots, we are human and have minds of our own! Let's not forget to use them to deviate from the norm when necessary and appropriate.

 

[Apollyon]

I would hope that if I was shot in the chest in rural america that I would be given every opportunity to be treated (CT surgeon or not).... Furthermore, I think you need to use your judgement on a case-by-case basis... Guidelines are just that--"guidelines". We are not robots, we are human and have minds of our own! Let's not forget to use them to deviate from the norm when necessary and appropriate.

I understand and appreciate your passion, but, at the same time, almost invariably, when ED thoracotomy is involved, all roads lead not to Rome, but the morgue. Without CT surgery backup, blunt trauma, no indication. No pulses in the field, virtually no indication. Loses pulses in the ED, depends on injury. Stab wounds? Minimal to rarely. GSW - worse.

J Am Coll Surg. 2000 Mar;190(3):288-98.

Survival after emergency department thoracotomy: review of published data from the past 25 years.

Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N.

Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.

BACKGROUND: Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT. STUDY DESIGN: Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates. RESULTS: EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death. CONCLUSIONS: The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors-MOI, LOMI, and SOL-should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.

Publication Types:

* Multicenter Study


PMID: 10703853 [PubMed - indexed for MEDLINE]

So, if you're in the middle of nowhere, even if you get a save, what's the next stop? The floor? ED thoracotomy is a temporizing measure in many cases (notwithstanding virtually a lifesaving maneuver) - if, indeed, there is a hospital close enough for transfer.

These are all "if"s, of course - but, no randomized controlled study or multicenter study is complete without an opposing anecdote (a/k/a "case report"):

J Trauma. 1994 Jan;36(1):131-4.

Successful roadside resuscitative thoracotomy: case report and literature review.

Wall MJ Jr, Pepe PE, Mattox KL.

Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, TX 77030.

Patients with injuries severe enough to require cardiopulmonary resuscitation (CPR) have a dismal prognosis. Time to surgical intervention is a major determinant of outcome in moribund trauma patients who have a potential for survival. With the exception of endotracheal intubation during evacuation to surgical intervention, no other usual prehospital procedures have been validated to affect outcome in such cases of extremis. This is a report of a case in which resuscitative surgical techniques were extended successfully to the prehospital environment. The patient was a 30-year-old man in extremis after a stab wound to the left chest. Estimating a transport time of 15 minutes, a physician riding with the emergency medical service (EMS) crews elected to perform a resuscitative thoracotomy. Following digital aortic compression, the patient regained both blood pressure and consciousness by the time of arrival at the trauma center. A left lower lobectomy was then performed in the operating room. The patient recovered fully and was discharged home in 21 days, neurologically intact. Four years later, the patient was alive, healthy, and working. This report demonstrates the feasibility of prehospital thoracotomy and raises provocative issues regarding future intense surgical involvement in prehospital care.

Publication Types:

* Case Reports
* Review
* Review of Reported Cases


PMID: 8295241 [PubMed - indexed for MEDLINE]

A final thought is competency - another question is, what is the likelihood of a BC/BE EM-trained doc being at SUCH a rural hospital, there isn't CT or general surgery available? The numbers say, exceedingly unlikely - they just aren't there.

Oh, wait - one last thought -

Am Surg. 1994 Jun;60(6):401-4.

Gunshot wounds: 10-year experience of a rural, referral trauma center.

Dodge GG, Cogbill TH, Miller GJ, Landercasper J, Strutt PJ.

Department of Surgery, Gundersen Clinic, Ltd., La Crosse, Wisconsin 54601.

The 10-year experience of a Level II trauma center with 122 gunshot wounds referred from a large rural area was analyzed to illustrate differences from the experience of urban centers. Most frequent causes of injury were attempted suicide in 38 (31%) patients, hunting mishaps in 32 (26%), unintentional accidents in 29 (24%), and intentional assault in 18 (15%). Of weapons specified, rifles were documented in 48 (39%) instances, shotguns in 25 (21%), and handguns in 24 (20%). Body regions injured were the trunk in 47 (39%) patients, head in 35 (29%), lower extremity in 31 (25%), and upper extremity in 29 (24%). Twenty-five patients (20%) died as a result of their injuries. The cause of death was brain injury in 18 (72%), exsanguination from truncal wounds in 5 (20%), myocardial infarction in 1 (4%), and multiple organ failure in 1 (4%). We conclude that the distributions of cause and type of gunshot wounds are unique in a rural setting. These differences have profound consequences in designing effective prevention programs for our area and support the design of more efficient trauma systems for rural North America.

PMID: 8198327 [PubMed - indexed for MEDLINE]

If you're going to be shot in the rural, rural hinterlands (and it's not by your own hand), it's 3:1 rifle/shotgun vs. handgun. In that rifles and shotgun for the greater part are more powerful than handguns, and you get shot - the one doc and one nurse in that ED are likely to be slightly overwhelmed to crack your chest (because of the heavy trauma a shotgun or rifle inflict), and, unfortunately, you're out of luck.

Sorry for the long post.

 

[waterski232002]

Thanks for the articles...

As for passion or anything like that... I do not think it has anything to do with passion/emotion. My broader point was that as physicians we need to be able to think outside the box. Like I said in the earlier post, every situation depends on the circumstances at hand. We can not make generalizations that if a person lives in a rural area they "probably got shot by a shotgun"... or that there will be "no CT surgeon within a reasonable transport distance". It all depends on the case presented at hand. With the articles that are posted above, it is obvious that EDT can be a life-saving procedure in certain circumstances and I feel that it should be the determination of the EM physician whether to proceed or not (not a blanket contra-indication b/c there is no CT surgeon available).

Additionally, we can not use overall mortality post-procedure as the only guage to determine the utility of using that procedure. If we did this, then nobody would use CPR (overall mortality of an in-hospital code is >90%... and <5% of resuscitated patients who have coded actually make it to hospital discharge). This has a much worse outcome than the above cited EDT; however, we still do it. Would anyone suggest we not do CPR? I am not... but I would agree there are instances where we can just call the code and not proceed. Again, it's all about thinking outside the box and making decisions based on the individual case.

 

[edinOH]

Additionally, we can not use overall mortality post-procedure as the only guage to determine the utility of using that procedure. If we did this, then nobody would use CPR (overall mortality of an in-hospital code is >90%... and <5% of resuscitated patients who have coded actually make it to hospital discharge). This has a much worse outcome than the above cited EDT; however, we still do it. Would anyone suggest we not do CPR? I am not... but I would agree there are instances where we can just call the code and not proceed. Again, it's all about thinking outside the box and making decisions based on the individual case.

You don't have to find a surgeon to clean up your mess after you perform CPR.

 

[Apollyon]

Additionally, we can not use overall mortality post-procedure as the only guage to determine the utility of using that procedure. If we did this, then nobody would use CPR (overall mortality of an in-hospital code is >90%... and <5% of resuscitated patients who have coded actually make it to hospital discharge). This has a much worse outcome than the above cited EDT; however, we still do it. Would anyone suggest we not do CPR? I am not... but I would agree there are instances where we can just call the code and not proceed. Again, it's all about thinking outside the box and making decisions based on the individual case.

Well, I've become quite an advocate for end-tidal CO2 <16 and ultrasound showing no cardiac activity, to call the code right away. You're right, and I do fully agree, there are instances where we can just call the code and not proceed.

As far as the in-hospital mortality >90%, data please!

 

[waterski232002]

I will clarify that statement... Not all in-hospital codes, but in-hospital codes without an immediately recognized reversible cause (tamponade, tension pneumo, etc). I do not have the article off-hand, but those stats have been cited numerous times to me during my unit months. I will try to find the exact article.

Here is a link to an article which shows mortality of all out-of-hospital codes by bystandards vs. EMT vs. paramedics which shows overall mortality at approx 75-80% regardless of cause/rhythm if intervened early (within 4 minutes) vs. late intervention (CPR-defibrillation initiated after 4 minutes) where mortality is approx 85-98%. I realize that this is not the same, but at least most of these patients have recognizable causes for coding (V-fib or pulseless V-Tach) and their prognosis is still dismal.

http://www.americanheart.org/presenter.jhtml?identifier=3012022
(In brief... see table 1 and 2)

The point was that in-hospital codes confer a very dismal prognosis and that the vast majority of patients do not make it to a meaningful discharge... but we still do it.

You don't have to find a surgeon to clean up your mess after you perform CPR.

Just because a CT surgeon is needed to "clean up our mess" does not mean that we should not do a life-saving procedure. If I was worried about waking up my consultants and having them mad at me for burdening them with my short-comings, I sure as hell would not go into EM!

 

[edinOH]

If I was worried about waking up my consultants and having them mad at me for burdening them with my short-comings, I sure as hell would not go into EM!

That is good because you will do it often.

My point is that CPR and EDT are hardly fair comparisons, especially in a rural setting as mentioned earlier.

In a perfect world you would have a CT surgeon readily available to take your pt to the OR if your intervention was lifesaving/sustaining. But in that perfect world you probably wouldn't be the one doing it or making the decision to do it either. Otherwise the point is moot because the pt died despite the ribspreader in his chest. Dead is dead is dead.

I guess if you were in a rural setting and you opened a chest, made an intervention, and were able to get your pt. onto the helo with some vital signs, then I guess you can justify the procedure. When the pt dies, it really doesn't matter anyway from a medical point of view.

Of course the politics of the procedure are real and can be a pain in your ass. Especially in a rural (moonlighting) setting. You will inevitably have some old crusty family medicine doc who is the "ED director" or better yet the even older and crustier local general surgeon calling your program director asking if he heard about what that "damned cowboy ER resident of yours" did in his ER last night!

 

[Scrubbs]

Just because a CT surgeon is needed to "clean up our mess" does not mean that we should not do a life-saving procedure. If I was worried about waking up my consultants and having them mad at me for burdening them with my short-comings, I sure as hell would not go into EM!

Not to get in the middle of the mud-slinging, but EDT in a rural/community setting is very different from EDT when its a matter of just waking up your in house/local trauma surgeon. My program spends about 50% of our ED months at very busy community hospitals. We have in-house surgery residents, but they aren't going to perform definitive care after an EDT. Hell, we transfer anything hand/optho/some ENT - forget about even discussing trauma.

I could care less about making consultants mad. That being said, I also know how long it takes to transfer a patient to a higher level facility. In the best of circumstances, we'd be able to get a 911 ambulance to come pick up the patient and bring them to our nearest trauma center - just 15 minutes away. However, from the time the patient would hit the door with us to getting them to an OR would probably be >1hr. I highly doubt the survival rates for a transferred EDT would approach 7%.

I can't imagine cross clamping an aorta, throwing some gauze over the clamshell incision I made, and sticking the patient in an ambulance... doesn't quite work.

 

[waterski232002]

If I was worried about waking up my consultants and having them mad at me for burdening them with my short-comings, I sure as hell would not go into EM!

That comment was written for EdinOH and his earlier post...(sigh) I realize that EM consists of consult, consult, consult, and it doesn't bother me... that's obviously why I'm okay with doing EM!