I need more supervision!

[Heeed!]

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So there I was two nights ago and three traumas come in at the same time. The first trauma is a mutliple GSW: shot #1 is a through and through on the elbow, shot #2 has an entry on the upper right back w/o an exit, and shot #3 deeply grazed the patient across the chin. He's combative at the beginning, GCS 14, and I'm helping the med student learn how to fill out the trauma sheet while everyone is yelling and running around. I remark to her that she'll get to close his chin when this is all done. The second trauma is another GSW but I'm still helping the student and our patient starts going downhill: decreased breath sounds, no pulse in right upper extremity, decreased mental status. So the surgery trauma staff are going back and forth between the two trauma bays. The third trauma comes in and I take that one. Meanwhile, 6 units have been hung on the first GSW along with multiple FFP's. He's already intubated. The chest tube that gets placed gushes about 500cc's as soon as it's unclampled. He's obviously getting rushed to the OR. My trauma is a female who is drunk and has a 7cm laceration above her left eyebrow 2/2 getting hit with a rock thrown over a fence (at 0300)🙄. Doesn't look bad but her eye is proptotic, her 6mm left pupil is fixed, and there's an obvious step-off inside the wound. So I rush her to the CT scanner and am surprised at the results: frontal bone fx, nasal bone fx, lateral and posterior orbital wall fxs, zygomatic fx, pneumocephalus. I consult OFMS who is on face for the last 1/2 of the month: "No problem. I'll be there shortly." Neurosurgery consult for air in the cranium: "I'm on my way." Ophthomology consult for proptotic globe and fixed pupil. "Ugh! I just left the hospital. It's going to take me AT LEAST 40 minutes to get back in" (spoken in exasperated, whiney female voice). I ask is there anything I can do until she gets here. "Yes," she says, "start measuring the globe pressures and if it gets too high, perform a lateral canthotomy." "Umm....I guess I could try that but..." "Let me talk to your attending right now" she says. I explain he's in the OR with GSW #1. (As soon as they made the thoracotomy incision, he exploded the rest of his blood volume all over the OR...bullet hit his innominate artery and he was bleeding out all over the place). So then she starts laying into me: "You need more supervision. You can't be allowed to handle this situation by yourself. When this is all over, you need to go to the ER and get some remedial training. This is ridiculous!" I explain that I'm eager to clamp the corner of her eyelid and start cutting ligaments and muscles and everything, but instead of chewing me out how about driving fast, getting in here, and doing your friggin' job?
Then, after I tuck her in the SICU, talk with the family for 30 minutes, and finish all the paperwork, I give Ophtho a courtesy call to let her know the patient is in bed xxx. (It has been about an hour now since I called her). "Yeah, I figured that out all by myself. I've been looking at the scans for about 10 minutes now and blah, blah, blah." Meanwhile, I'm thinking why did she decide to log into the computer system, start Centricity, and comfy up to all the images vs. (at least) getting a quick look at the patient? Then she starts in again: "You know, you really can't consider yourself a competent doctor until you're comfortable measuring globe pressures, performing a canthotomy, etc. etc."😴 I'M NOT GOING TO PERFORM EYE SURGERY ON ANYONE...THAT'S WHY I'M CALLING YOU OPHTHO RESIDENT!!! AND I'M PRETTY SURE WHEN YOU'RE ON HOME CALL, YOU'RE REQUIRED TO RESPOND IN <30 MINUTES...OTHERWISE YOU NEED TO BE TAKING IN-HOUSE CALL!!!! Next time I'll call the attending, tell him to leave the OR and supervise me more.🙄 If a civilian provider did that, her career would be over. That would be the last consult she would ever get from anyone. JUST DO YOUR DANG JOB!! sheesh.

 

[JetFlyer]

Wow

 

[The White Coat Investor]

Where's the emergency doc? He is the one who should be taking care of that emergent lateral canthotomy. Good trauma care requires both trauma surgery AND emergency medicine.

 

[bogatyr]

So there I was two nights ago and three traumas come in at the same time. The first trauma is a mutliple GSW: shot #1 is a through and through on the elbow, shot #2 has an entry on the upper right back w/o an exit, and shot #3 deeply grazed the patient across the chin. He's combative at the beginning, GCS 14, and I'm helping the med student learn how to fill out the trauma sheet while everyone is yelling and running around. I remark to her that she'll get to close his chin when this is all done. The second trauma is another GSW but I'm still helping the student and our patient starts going downhill: decreased breath sounds, no pulse in right upper extremity, decreased mental status. So the surgery trauma staff are going back and forth between the two trauma bays. The third trauma comes in and I take that one. Meanwhile, 6 units have been hung on the first GSW along with multiple FFP's. He's already intubated. The chest tube that gets placed gushes about 500cc's as soon as it's unclampled. He's obviously getting rushed to the OR. My trauma is a female who is drunk and has a 7cm laceration above her left eyebrow 2/2 getting hit with a rock thrown over a fence (at 0300)🙄. Doesn't look bad but her eye is proptotic, her 6mm left pupil is fixed, and there's an obvious step-off inside the wound. So I rush her to the CT scanner and am surprised at the results: frontal bone fx, nasal bone fx, lateral and posterior orbital wall fxs, zygomatic fx, pneumocephalus. I consult OFMS who is on face for the last 1/2 of the month: "No problem. I'll be there shortly." Neurosurgery consult for air in the cranium: "I'm on my way." Ophthomology consult for proptotic globe and fixed pupil. "Ugh! I just left the hospital. It's going to take me AT LEAST 40 minutes to get back in" (spoken in exasperated, whiney female voice). I ask is there anything I can do until she gets here. "Yes," she says, "start measuring the globe pressures and if it gets too high, perform a lateral canthotomy." "Umm....I guess I could try that but..." "Let me talk to your attending right now" she says. I explain he's in the OR with GSW #1. (As soon as they made the thoracotomy incision, he exploded the rest of his blood volume all over the OR...bullet hit his innominate artery and he was bleeding out all over the place). So then she starts laying into me: "You need more supervision. You can't be allowed to handle this situation by yourself. When this is all over, you need to go to the ER and get some remedial training. This is ridiculous!" I explain that I'm eager to clamp the corner of her eyelid and start cutting ligaments and muscles and everything, but instead of chewing me out how about driving fast, getting in here, and doing your friggin' job?
Then, after I tuck her in the SICU, talk with the family for 30 minutes, and finish all the paperwork, I give Ophtho a courtesy call to let her know the patient is in bed xxx. (It has been about an hour now since I called her). "Yeah, I figured that out all by myself. I've been looking at the scans for about 10 minutes now and blah, blah, blah." Meanwhile, I'm thinking why did she decide to log into the computer system, start Centricity, and comfy up to all the images vs. (at least) getting a quick look at the patient? Then she starts in again: "You know, you really can't consider yourself a competent doctor until you're comfortable measuring globe pressures, performing a canthotomy, etc. etc."😴 I'M NOT GOING TO PERFORM EYE SURGERY ON ANYONE...THAT'S WHY I'M CALLING YOU OPHTHO RESIDENT!!! AND I'M PRETTY SURE WHEN YOU'RE ON HOME CALL, YOU'RE REQUIRED TO RESPOND IN <30 MINUTES...OTHERWISE YOU NEED TO BE TAKING IN-HOUSE CALL!!!! Next time I'll call the attending, tell him to leave the OR and supervise me more.🙄 If a civilian provider did that, her career would be over. That would be the last consult she would ever get from anyone. JUST DO YOUR DANG JOB!! sheesh.

Don't worry Heeed. When you start anesthesia you won't be allowed to pick your nose without calling your attending first.

 

[a1qwerty55]

If a civilian provider did that, her career would be over. That would be the last consult she would ever get from anyone. JUST DO YOUR DANG JOB!! sheesh.

Obviously you haven't tried to get an after hours ENT or Ophtho consult in the civilian world. Few take call, none come in without throwing rocks at you.

 

[The White Coat Investor]

Obviously you haven't tried to get an after hours ENT or Ophtho consult in the civilian world. Few take call, none come in without throwing rocks at you.

Agree that ENT is often a tough one. However, at one large Navy academic center I've been uniformly impressed with the ENT consultants (granted, they're residents.) I have also been at places with exceptional Ophtho consultants. But, on average, you're probably right. Hand surgery, plastic surgery and neurosurgery at any non-trauma center isn't much better.

At any rate, a lateral canthotomy is a relatively simple procedure covered in emergency medicine residencies, usually through lecture and pig/dog/cadaver lab. It probably occurs at about the same frequency as a crichothyrotomy in an ED. A situation as described above, where the patient actually needs it AND the consultant cannot arrive in a timely manner is actually pretty rare. Nonetheless, emergency medicine is all about stuff that has to be done BEFORE a specialist can arrive. Intubations, central lines, LPs, fracture and dislocation reductions, procedural sedations, lateral canthotomies, initial treatment of arrythmias, strokes, sepsis, head trauma, and MIs, trauma resuscitations, etc. Bear in mind that a Level II trauma center does not have a general/trauma surgeon in house and they can be up to 30 minutes away.

 

[Heeed!]

Where's the emergency doc? He is the one who should be taking care of that emergent lateral canthotomy. Good trauma care requires both trauma surgery AND emergency medicine.

Once I roll from the trauma bay to the scanner, I own the patient. That's why I want to create a CT machine that fits around the frame of the trauma bay door. We hook the patient's bed onto a pulley system (like the chain thing on a roller coaster that pulls you up the first hill) and scan them as they enter the trauma bay. That way, all the scans are being processed while the team is working on the patient, and nobody goes blind because I don't have enough supervision.👍

 

[The White Coat Investor]

Once I roll from the trauma bay to the scanner, I own the patient. That's why I want to create a CT machine that fits around the frame of the trauma bay door. We hook the patient's bed onto a pulley system (like the chain thing on a roller coaster that pulls you up the first hill) and scan them as they enter the trauma bay. That way, all the scans are being processed while the team is working on the patient, and nobody goes blind because I don't have enough supervision.👍

I'm not sure how much of your comment is in jest, as I have, believe it or not, see very serious proposals for something for the sort, for plain films and CT. But I'm not sure how that would improve your supervision. It didn't sound like your situation was created by lack of early CT scans. Your situation was created by the fact that you "own the patient." In the ideal world, the patient is still shared by a staff-level emergency doc until the patient is sufficiently stabilized to be moved upstairs. A patient needing an emergent lateral canthotomy is NOT sufficiently stabilized to go upstairs, especially into the care of an undersupervised physician-in-training when his supervision has their hands full in the OR.

 

[pgg]

"Ugh! I just left the hospital. It's going to take me AT LEAST 40 minutes to get back in"

[...]

I'M PRETTY SURE WHEN YOU'RE ON HOME CALL, YOU'RE REQUIRED TO RESPOND IN <30 MINUTES...OTHERWISE YOU NEED TO BE TAKING IN-HOUSE CALL!!!!

QCR her for being >30 min out on her call night. Seriously. Unless you have real fear of retaliation, don't put up with abuse from someone who is herself behaving in an indefensible and unprofessional manner.

 

[deleted6669]

"I can also count on one hand the number of ER Attendings proficient with the tonometer"

I truly hope you are kidding....EVERY emergency medicine md and pa I work with knows how to use these and before the neato digital tonopens we used schiotz tonometers....we can all do slit lamp exams too....
but I agree with most of your other points, trauma is for the most part surgical dz.
we have sketchy ophtho coverage( someone always on call but never wants to come in) and excellent ent coverage.

 

[The White Coat Investor]

I assume you're joking? Having rotated through three Level 1's, I have yet to see an ER doc do anything useful in trauma (except my last facility, where they were responsible for airway during trauma codes . . . and I think everyone here can imagine how great that worked out). Trauma Surgery manages it all.

I can also count on one hand the number of ER Attendings proficient with the tonometer. I can't imagine a single one doing a canthotomy.

How unfortunate for you, as you've obviously seen one example of what happens when "surgery manages it all." I saw anesthesia in the ER once during my three-year residency, to reintubate a 10 year old I had already intubated but the trauma attending didn't believe it. Can't really blame him, since the sats continued to drop and the patient continued to deteriorate after the intubation. Perhaps it was the 8 cm tracheal lac and the detached bronchus suffered in the trauma that made it seem like there wasn't a patent airway from vent to alveoli. The patient died in the OR after he opened her chest and declared her injuries inoperable (which was absolutely true.)

And tonometers? Come on. Where are your emergency attendings trained?

Newsflash! Most trauma ISN'T surgical. The percentage of trauma cases (even "trauma codes" taken to Level 1 trauma centers) that actually goes to an OR, much less needs to go to an OR within 30 minutes of arrival, is low. Is a trauma surgeon an indispensable part of the trauma team? Of course. But a good trauma team requires good trauma nurses, good trauma paramedics and techs, good emergency physicians, good OR staff, good ward/ICU staff, AND good surgeons. If you're missing any one of these elements, the team won't be as good. Who do you think is resuscitating the other traumas in the ED when the surgeons are in the OR? (Apparently at your place, it's you, but it doesn't have to be that way.)

For those interested in learning a bit about lateral canthotomies, I refer you to emedicine's handy article (with videos)

1. 
   [*]Provide adequate anesthesia by injecting 1 mL of lidocaine 1-2% with epinephrine into the lateral canthus. The combination of lidocaine with epinephrine assists with hemostasis and local anesthesia.
   
   [*]Confirm the affected eye and perform a repeat inspection, noting the typical findings of unilateral proptosis, an afferent pupillary defect, decreased visual acuity, and an IOP of 40 mm Hg or higher.
   
   [*]Irrigate the eye with normal saline to clear away debris that may enter the eye or interfere with the procedure.
   
   [*]Use a straight hemostat to crimp the skin at the lateral corner of the patient's eye. This crimp functions to achieve hemostasis and to mark the location where the incision is to be made.
   
   
   Crimping the lateral orbital canthus to mark where to cut the skin.
   
   [*]Use forceps to pick up the skin around the lateral orbit.
   
   [*]Use the scissors to make a 1-2 cm incision beginning at the lateral corner of the eye and extending laterally outward.
   
   
   Cutting the lateral orbital canthus.
   
   [*]This incision decreases some pressure but is often insufficient alone; therefore, proceed to cantholysis.
   
   [*]Retract the inferior lid downward to visualize the lateral canthus tendon.
   
   [*]With the scissors directed along the lateral orbital rim (pointing away from the globe), dissect the inferior crux of the lateral canthus tendon and cut it.
   
   
   Cutting the inferior canthal ligament.
   
   [*]If this procedure is insufficient (ie, IOP remains >40 mm Hg), cut the superior portion of the lateral tendon by dissecting superiorly before cutting it.

http://www.emedicine.com/proc/topic82812.htm

 

[usnavdoc]

Don't worry Heeed. When you start anesthesia you won't be allowed to pick your nose without calling your attending first.

What program are you in? Thats insane.

 

[BigNavyPedsGuy]

How unfortunate for you, as you've obviously seen one example of what happens when "surgery manages it all." I saw anesthesia in the ER once during my three-year residency, to reintubate a 10 year old I had already intubated but the trauma attending didn't believe it. Can't really blame him, since the sats continued to drop and the patient continued to deteriorate after the intubation. Perhaps it was the 8 cm tracheal lac and the detached bronchus suffered in the trauma that made it seem like there wasn't a patent airway from vent to alveoli. The patient died in the OR after he opened her chest and declared her injuries inoperable (which was absolutely true.)

And tonometers? Come on. Where are your emergency attendings trained?

Newsflash! Most trauma ISN'T surgical. The percentage of trauma cases (even "trauma codes" taken to Level 1 trauma centers) that actually goes to an OR, much less needs to go to an OR within 30 minutes of arrival, is low. Is a trauma surgeon an indispensable part of the trauma team? Of course. But a good trauma team requires good trauma nurses, good trauma paramedics and techs, good emergency physicians, good OR staff, good ward/ICU staff, AND good surgeons. If you're missing any one of these elements, the team won't be as good. Who do you think is resuscitating the other traumas in the ED when the surgeons are in the OR? (Apparently at your place, it's you, but it doesn't have to be that way.)

For those interested in learning a bit about lateral canthotomies, I refer you to emedicine's handy article (with videos)

1. 
   [*]Provide adequate anesthesia by injecting 1 mL of lidocaine 1-2% with epinephrine into the lateral canthus. The combination of lidocaine with epinephrine assists with hemostasis and local anesthesia.
   
   [*]Confirm the affected eye and perform a repeat inspection, noting the typical findings of unilateral proptosis, an afferent pupillary defect, decreased visual acuity, and an IOP of 40 mm Hg or higher.
   
   [*]Irrigate the eye with normal saline to clear away debris that may enter the eye or interfere with the procedure.
   
   [*]Use a straight hemostat to crimp the skin at the lateral corner of the patient’s eye. This crimp functions to achieve hemostasis and to mark the location where the incision is to be made.
   
   
   Crimping the lateral orbital canthus to mark where to cut the skin.
   
   [*]Use forceps to pick up the skin around the lateral orbit.
   
   [*]Use the scissors to make a 1-2 cm incision beginning at the lateral corner of the eye and extending laterally outward.
   
   
   Cutting the lateral orbital canthus.
   
   [*]This incision decreases some pressure but is often insufficient alone; therefore, proceed to cantholysis.
   
   [*]Retract the inferior lid downward to visualize the lateral canthus tendon.
   
   [*]With the scissors directed along the lateral orbital rim (pointing away from the globe), dissect the inferior crux of the lateral canthus tendon and cut it.
   
   
   Cutting the inferior canthal ligament.
   
   [*]If this procedure is insufficient (ie, IOP remains >40 mm Hg), cut the superior portion of the lateral tendon by dissecting superiorly before cutting it.

http://www.emedicine.com/proc/topic82812.htm

Dude! You shold've jsut looked on e-medicine. That's all the supervision you need (obviously I'm kidding - thanks for the video)

 

[tkim]

Would you do this in the ED?

One of the other EM interns did this in the ED couple months ago, with attending supervision, of course. Optho was stuck somewhere and the pt's IOP pressure was high. Wish I had been there.

 

[The White Coat Investor]

Would you do this in the ED?

If it's 3 am, ophtho won't answer a call (or can't arrive for an hour for whatever reason) and the patient has an IOP of 70 or some other crazy number...yes. If ophtho is in the clinic next door and promises to be there in 5 minutes, or the patient has a pressure of 28...then probably not.

 

[The White Coat Investor]

If it's 3 am, ophtho won't answer a call (or can't arrive for an hour for whatever reason) and the patient has an IOP of 70 or some other crazy number...yes. If ophtho is in the clinic next door and promises to be there in 5 minutes, or the patient has a pressure of 28...then probably not.

And of course, you still need ophtho to put them back together eventually. It's like doing a thoracotomy. Sure, you might miraculously save their life, but if there isn't a surgeon at your hospital that can put their chest back together...what's the point?

 

[orbitsurgMD]

And of course, you still need ophtho to put them back together eventually. It's like doing a thoracotomy. Sure, you might miraculously save their life, but if there isn't a surgeon at your hospital that can put their chest back together...what's the point?

Canthotomy and release of the inferior crus of the lateral canthal tendon is simple and quick. Anaesthesia with whatever you have in an injectable, preferaly xylocaine. Two cuts are enough; it is about the simplest thing you can do with a pair of Westcott scissors. It is bloody, and it is supposed to be; in fact that is what you hope it will be. Repair issues are secondary and can and should be delayed for an extended time, well past the period of danger. They don't have to be repaired in-house. The indications are likewise simple: acute proptosis arising from trauma with elevated IOP and a high suspicion of hemorrhage. You do not need a CT to justify performing this procedure. You don't need an ophthalmologist's blessing either.