Level 1 Trauma Case CRM skills

[ethilo]

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Had a case involving a level 1 trauma needing massive transfusion the other day and a few questions came up I was hoping to run by others. Major MVC with pelvic bleeding, traumatic arm amputation. Ended up getting the thoracotomy, cardiac massage, and eventually expired. Transfused around 50 units total in about 45 mins worth of time.

We are taught crisis resource management to "step back" and to delegate to others. I find it uncomfortable in the real-world scenarios to "leave the pocket" maybe because I feel like I get disconnected from the information and/or it gets done better if I do it myself (which can be a setup for tunnel vision). Does anyone intentionally step back and allow others to take over that space while directing from afar?

Any general sage advice or personal approaches you developed in these cases for how to keep a handle on the situation? Have you developed any protocol within yourself so that you systematically work through these high stakes cases?

 

[deleted697535]

50 units under an hour? Forget it mate. That's a sh1t show. No one can organise that successfully

Personally I have a custom alarm app on my phone that sets alarms for me q20mins that I run for AAA or bad ectopics or bleeders in general . Just simple things like check coags abg give txa fibrigogen calcium bicarb, recheck tube via bronch, call ICU bla bla bla.

I tell everyone incl residents/fellows that not 1 single drug is pushed unless it goes thru me. If they disobey me once theyre out. Politely out but definitely out. I like to send them to set up a second level 1 transfuser or cell saver. II delegat a middle level resident to chart. This is probably one of the.most important tasks so they might dislike it but it must be mid to senior level. Not junior.

But I'm not aware of any evidence for any of this

Most important is reminder be polite to everyone. And remain calm.

I'm lucky or unlucky enough to have seen enough of these that it's a toss of a coin to whether these survive. All we do is blow at the coin. If we're lucky we blow it to heads

 

[dchz]

The most optimal way to handle things depends on how many people you have on your team;

Jobs involved:
1.Assessing the situation.
2.Determining the treatment.
3.Executing the treatment
4.Executing the blood hanging.
5.Supplemental drugs preparation.
6.Obtaining necessary equipment/supplies not available in the OR.

Everyone involved needs to:
Call out relevant findings succinctly.
Use closed-loop communications.
Have an established hierarchy and understand the gravity of the situation.

My first day of anes in residency , i went into a MTP that transfused 128/128/6 (pretty much all the stuff we had in the hospital). The guy had 5 hollow points to his torso (he didn't make it after another 30/30/2). The job was handled surprising well by 1 CA-3, 2 CA-2, and 1 CA-1.

It wasn't the cleanest thing, but it was executed very well given how we were all trainees: (attending stood off to the side)

CA-3 stood at head of the bed and did jobs 1,2,3.
CA-2s executed job 4
CA-1 executed job 5 and charting for the blood.
Anesthesia tech executed almost all of job 6.

I think MTPs can be handled by 2 people if they have good rapport. The break down for me would go one person handles job 1,2,3,5, and the other handle job 4, 6. But the key to this is execution, lots of people don't find it natural or know when to communicate and when to observe. @Newtwo is right that everyone has to remain calm, I find it easy to stay calm when i focus on the object facts rather than the pace of the situation.

 

[deleted171991]

Had a case involving a level 1 trauma needing massive transfusion the other day and a few questions came up I was hoping to run by others. Major MVC with pelvic bleeding, traumatic arm amputation. Ended up getting the thoracotomy, cardiac massage, and eventually expired. Transfused around 50 units total in about 5 mins worth of time.

We are taught crisis resource management to "step back" and to delegate to others. I find it uncomfortable in the real-world scenarios to "leave the pocket" maybe because I feel like I get disconnected from the information and/or it gets done better if I do it myself (which can be a setup for tunnel vision). Does anyone intentionally step back and allow others to take over that space while directing from afar?

Any general sage advice or personal approaches you developed in these cases for how to keep a handle on the situation? Have you developed any protocol within yourself so that you systematically work through these high stakes cases?

I haven't worked in a level 1 center since residency (thank gods), but I have the occasional major ****fest in the OR or the ICU. I find that stepping back improves my perspective significantly (as long as we have the human resources for that). It takes a very clear mind to both run the "code" and do stuff to the patient (it's hard not to develop "tunnel vision"). I only intervene if there is something that I would do much-much better and it would improve the outcome significantly.

In your patient, there is NOTHING that would have saved him, even if the bleeding had been stopped. Once you get to replacing the blood volume a few times, the immune response will probably kill the patient (ARDS, DIC, MODS etc.), unless young and strong. I honestly don't know why we don't have clear protocols to limit the total amount of blood products one can waste on a futile resus.

 

[anbuitachi]

I dont think ive ever seen someone walk out of the hospital after getting 150+ units of products

50 units under an hour? Forget it mate. That's a sh1t show. No one can organise that successfully

Personally I have a custom alarm app on my phone that sets alarms for me q20mins that I run for AAA or bad ectopics or bleeders in general . Just simple things like check coags abg give txa fibrigogen calcium bicarb, recheck tube via bronch, call ICU bla bla bla.

I tell everyone incl residents/fellows that not 1 single drug is pushed unless it goes thru me. If they disobey me once theyre out. Politely out but definitely out. I like to send them to set up a second level 1 transfuser or cell saver. II delegat a middle level resident to chart. This is probably one of the.most important tasks so they might dislike it but it must be mid to senior level. Not junior.

But I'm not aware of any evidence for any of this

Most important is reminder be polite to everyone. And remain calm.

I'm lucky or unlucky enough to have seen enough of these that it's a toss of a coin to whether these survive. All we do is blow at the coin. If we're lucky we blow it to heads

I mean everyone should have a job, but kicking someone out just for that? Brutal man. Would not want to be in that OR. What happens after you kick out all your residents? You'd just be doing it all yourself

 

[Psai]

The most optimal way to handle things depends on how many people you have on your team;

Jobs involved:
1.Assessing the situation.
2.Determining the treatment.
3.Executing the treatment
4.Executing the blood hanging.
5.Supplemental drugs preparation.
6.Obtaining necessary equipment/supplies not available in the OR.

Everyone involved needs to:
Call out relevant findings succinctly.
Use closed-loop communications.
Have an established hierarchy and understand the gravity of the situation.

My first day of anes in residency , i went into a MTP that transfused 128/128/6 (pretty much all the stuff we had in the hospital). The guy had 5 hollow points to his torso (he didn't make it after another 30/30/2). The job was handled surprising well by 1 CA-3, 2 CA-2, and 1 CA-1.

It wasn't the cleanest thing, but it was executed very well given how we were all trainees: (attending stood off to the side)

CA-3 stood at head of the bed and did jobs 1,2,3.
CA-2s executed job 4
CA-1 executed job 5 and charting for the blood.
Anesthesia tech executed almost all of job 6.

I think MTPs can be handled by 2 people if they have good rapport. The break down for me would go one person handles job 1,2,3,5, and the other handle job 4, 6. But the key to this is execution, lots of people don't find it natural or know when to communicate and when to observe. @Newtwo is right that everyone has to remain calm, I find it easy to stay calm when i focus on the object facts rather than the pace of the situation.

Using that many products on one person sounds like a waste. I get that you're taking care of the patient in front of you but it's not like obtaining blood products is easy or cheap and there are many others in the hospital who need them.

 

[dchz]

I dont think ive ever seen someone walk out of the hospital after getting 150+ units of products

Gina Walker disagrees

" save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."lTo save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."

 

[dchz]

Using that many products on one person sounds like a waste. I get that you're taking care of the patient in front of you but it's not like obtaining blood products is easy or cheap and there are many others in the hospital who need them.

This brings up a great point. Obv as a ca-1 on my first day I didn't bring this up. But many have brought it up after the fact.

Poll to the posters: when do you bring up stopping? The pt in my first MTP above was a 30 M with no other comorbidities.

 

[anbuitachi]

Gina Walker disagrees

" save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."lTo save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."

This brings up a great point. Obv as a ca-1 on my first day I didn't bring this up. But many have brought it up after the fact.

Poll to the posters: when do you bring up stopping? The pt in my first MTP above was a 30 M with no other comorbidities.

Yea these young ones are definitely the exception. But for older people the attending in charge should definitely stop after a certain point but of course it depends on teh clinical picture.

 

[T-burglar]

unless you’ve practiced these cases with a team of veteran operators who all want the responsibility and want to do a good job, they will always be a chaotic circus.

 

[IMGASMD]

Yea these young ones are definitely the exception. But for older people the attending in charge should definitely stop after a certain point but of course it depends on teh clinical picture.

Had one AAA ruptured/dissection. Guy was like 80 something. Younger attending was pumping in blood, surgical team doing chest compression. One of more seasoned attending came, just said stop. WTF are you guys doing?! That was the end of it.

 

[dhb]

Had one AAA ruptured/dissection. Guy was like 80 something. Younger attending was pumping in blood, surgical team doing chest compression. One of more seasoned attending came, just said stop. WTF are you guys doing?! That was the end of it.

But GOMERS don't die...!

 

[ethilo]

Thanks for all the tips. Really appreciate the feedback. Good things to mill over.

An additional thing: how/when do you assume control of the patient in the trauma bay? Something I noticed was how much calmer the mood got after we wheeled the patient out of the ED and on to the OR despite the patient continuing to get worse.

One thing I've considered is forcefully whisking them out before the ED works on getting more access, simply because we can do it faster and with more certainty in the OR. I guess that decision will be based on whether or not I would think the patient will survive the transit to the OR without having had some resusc first...

 

[ethilo]

BTW this patient in my OP was 18 year old otherwise healthy

 

[NICMAN]

Gina Walker disagrees

" save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."lTo save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."

Yup, I remember that incident when I was a med student there in San Antonio.

 

[abolt18]

Gina Walker disagrees

" save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."lTo save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."

They talked about this several times when I interviewed there. Pretty wild story!

 

[anbuitachi]

Thanks for all the tips. Really appreciate the feedback. Good things to mill over.

An additional thing: how/when do you assume control of the patient in the trauma bay? Something I noticed was how much calmer the mood got after we wheeled the patient out of the ED and on to the OR despite the patient continuing to get worse.

One thing I've considered is forcefully whisking them out before the ED works on getting more access, simply because we can do it faster and with more certainty in the OR. I guess that decision will be based on whether or not I would think the patient will survive the transit to the OR without having had some resusc first...

I think it depends on the culture. Here the ED has control in trauma bay, until trauma surgeon shows up and either takes over or fight with ED about control. The anesthesiologist is not the leader in the trauma area. Usually by the time we get notified about a serious trauma, the patient has already been in the ED for some time and ED already has some form of airway in and has already gotten/attempted access. We get control once patient goes to OR.

I dont know about other places but it's difficult to be the leader in a foreign environment. We dont have our drugs or our equipments.

 

[Hamhock]

Gina Walker disagrees

" save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."lTo save her life throughout a massive and seemingly unstoppable hemorrhage, doctors pumped an astonishing 540 units of blood and blood products into Walker — more than 35 gallons."

540 units over what period of time?
I suspect there's more to this story and more time over which this transfusion occurred -- like days more time.

That said, I am more interested in the OP's case.

50 units of blood in the ED for blunt trauma in one hour is not only tremendous waste, it is horrific resuscitation.

In fact, this doesn't even make sense to me. Where did the 50 units go? Where did the other products (FFP, plts) go? Where was the bleeding? I can't even imagine the coagulopathy 50 units in one hour would cause? And what about the electrolyte and osmotic derangement?

How many before the thoracotomy?

If the blunt trauma wasn't enough to kill this kid, 50 units in one hour surely would.

HH

 

[ethilo]

540 units over what period of time?
I suspect there's more to this story and more time over which this transfusion occurred -- like days more time.

That said, I am more interested in the OP's case.

50 units of blood in the ED for blunt trauma in one hour is not only tremendous waste, it is horrific resuscitation.

In fact, this doesn't even make sense to me. Where did the 50 units go? Where did the other products (FFP, plts) go? Where was the bleeding? I can't even imaging the coagulopathy 50 units in one hour would cause? And what about the electrolyte and osmotic derangement?

How many before the thoracotomy?

If the blunt trauma wasn't enough to kill this kid, 50 units in one hour surely would.

HH

You know, respectfully, there is more to the story but I'd rather not let this be about the exact management and I'd rather just make this thread about the CRM stuff.

 

[Cryc_to_the_point]

Are there places where Anesthesia runs the trauma bay?

 

[sigrhoillusion]

Are there places where Anesthesia runs the trauma bay?

Yea... Hell...

 

[fakin' the funk]

I dont think ive ever seen someone walk out of the hospital after getting 150+ units of products

It happens, so don't give up.