Observations of a frantic trauma

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fiznat

fiznat

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Hey guys-- been a while since I've posted here. This is something I posted on an EMS forum I frequent, but I thought it would be interesting to see what you guys have to say about it as well. Please forgive what may be lost in the translation between EMS and ED, but I think the point is fairly clear.

....

I was in the ED today dropping off a patient when I overheard a patch on the c-med radio saying that a trauma was coming in. ...GSW, 4 shots from a handgun into the patient's back, through the torso, and 4 exit wounds out the chest. You can hear yelling from the back of the rig as the driver is giving the patch, he reports that the patient cannot move his legs and is beginning to become combative as the hypoxia and blood loss begin to take hold.

The crew did a good job. The patient was spine-neck immobilized, the chest twice decompressed, IV established with fluids running, O2 provided along with assisted vents via BVM. Sinus tach on the monitor, and the little bleeding seemed to be well controlled. ...All this performed with a combative patient and --as I was told later-- a group of rowdy onlookers on-scene. It wasnt until they rolled into the trauma room that the chaos began to ensue.

Seriously the worst cluster I have ever seen. Had to be 15 ED docs, nurses and techs cramped into a trauma room designed for probably half that. Immediately people start yelling. "Get me gloves!" "Get this guy tubed NOW!" "Give me a blade! Give me a blade! Give me a blade!" People are pushing each other out of the way, lines are crossed and steps are missed. I watch a resident insert a chest tube and then - once its inserted - look around and wonder where the rest of his equipment was. He didnt set it up before cutting, so he starts yelling for it. Nobody gets any respect. Nurses are treated like idiots because they dont instantly provide equipment to doctors, techs are pushed out of the way as they struggle to help. Everybody is yelling.

By the time it was said and done, this patient got his chest cracked right in the bay, tubes inserted and lines of blood run. Probably 10 minutes in the trauma bay and he was rushed up to the OR. As the bed was rushed out of the room, the femoral line almost gets pulled out as the bags of blood fall to the floor. Someone gets knocked down.

I have never ever seen such horrible communication and teamwork before. This was not a trauma team, as the called for on the intercom, it was a collection of bigheaded doctors and angry nurses-- each screaming to have their voice heard over the chaos.

I've seen this trauma team work patients before, but not like this. Usually it is a moderate trauma -- an MVA or a fall. This GSW was one of those rare and fantastic traumas: the kind you get to pull all the tricks and procedures out for. Hell, the medic got to decompress the guy in the field -- twice! How often does that happen, right? ...But the rarity of it and the added stress seemed to take the trauma team and fracture it. What is normally a cohesive team performing organized assessment and treatment became a frantic collection of angry demands and rushed decisions. Not exactly what you would hope for if you were that poor patient on the stretcher.

Anyone ever seen this before? How does your ED trauma team work? Do you find that doctors tend to yell over the crowd as the issue demands, or is there actual calm collected teamwork? ...Even on the bad traumas? I know we struggle with this all the time in the field-- and I'm sure most of us are familiar with that whipped-up exciting urgency that can sometimes become overpowering on the really bad calls.... but we all consider it to be the mark of a good medic/EMT/firefighter to be able to rise above the chaos and organize. It bothers me that these (mostly) experienced ED physicians found this basic principle so difficult to achieve.

I have 5 years of experience in EMS as an EMT and now (almost! haha) a medic, but I have never seen this kind of frantic response before from an ED trauma team. I know this is a long post and a long story (I tried to make it interesting), but I'm interested to hear other people's observations of bad traumas run in the ED. Whats the best youve seen? The worst?
 
fiznat said:
Hey guys-- been a while since I've posted here. This is something I posted on an EMS forum I frequent, but I thought it would be interesting to see what you guys have to say about it as well. Please forgive what may be lost in the translation between EMS and ED, but I think the point is fairly clear.

....

I was in the ED today dropping off a patient when I overheard a patch on the c-med radio saying that a trauma was coming in. ...GSW, 4 shots from a handgun into the patient's back, through the torso, and 4 exit wounds out the chest. You can hear yelling from the back of the rig as the driver is giving the patch, he reports that the patient cannot move his legs and is beginning to become combative as the hypoxia and blood loss begin to take hold.

The crew did a good job. The patient was spine-neck immobilized, the chest twice decompressed, IV established with fluids running, O2 provided along with assisted vents via BVM. Sinus tach on the monitor, and the little bleeding seemed to be well controlled. ...All this performed with a combative patient and --as I was told later-- a group of rowdy onlookers on-scene. It wasnt until they rolled into the trauma room that the chaos began to ensue.

Seriously the worst cluster I have ever seen. Had to be 15 ED docs, nurses and techs cramped into a trauma room designed for probably half that. Immediately people start yelling. "Get me gloves!" "Get this guy tubed NOW!" "Give me a blade! Give me a blade! Give me a blade!" People are pushing each other out of the way, lines are crossed and steps are missed. I watch a resident insert a chest tube and then - once its inserted - look around and wonder where the rest of his equipment was. He didnt set it up before cutting, so he starts yelling for it. Nobody gets any respect. Nurses are treated like idiots because they dont instantly provide equipment to doctors, techs are pushed out of the way as they struggle to help. Everybody is yelling.

By the time it was said and done, this patient got his chest cracked right in the bay, tubes inserted and lines of blood run. Probably 10 minutes in the trauma bay and he was rushed up to the OR. As the bed was rushed out of the room, the femoral line almost gets pulled out as the bags of blood fall to the floor. Someone gets knocked down.

I have never ever seen such horrible communication and teamwork before. This was not a trauma team, as the called for on the intercom, it was a collection of bigheaded doctors and angry nurses-- each screaming to have their voice heard over the chaos.

I've seen this trauma team work patients before, but not like this. Usually it is a moderate trauma -- an MVA or a fall. This GSW was one of those rare and fantastic traumas: the kind you get to pull all the tricks and procedures out for. Hell, the medic got to decompress the guy in the field -- twice! How often does that happen, right? ...But the rarity of it and the added stress seemed to take the trauma team and fracture it. What is normally a cohesive team performing organized assessment and treatment became a frantic collection of angry demands and rushed decisions. Not exactly what you would hope for if you were that poor patient on the stretcher.

Anyone ever seen this before? How does your ED trauma team work? Do you find that doctors tend to yell over the crowd as the issue demands, or is there actual calm collected teamwork? ...Even on the bad traumas? I know we struggle with this all the time in the field-- and I'm sure most of us are familiar with that whipped-up exciting urgency that can sometimes become overpowering on the really bad calls.... but we all consider it to be the mark of a good medic/EMT/firefighter to be able to rise above the chaos and organize. It bothers me that these (mostly) experienced ED physicians found this basic principle so difficult to achieve.

I have 5 years of experience in EMS as an EMT and now (almost! haha) a medic, but I have never seen this kind of frantic response before from an ED trauma team. I know this is a long post and a long story (I tried to make it interesting), but I'm interested to hear other people's observations of bad traumas run in the ED. Whats the best youve seen? The worst?
Click to expand...


I expect your post is going to start a long thread...

I'll keep my two points short:

First, it emphasizes the role -- however chessy -- of a pre-arrival conference. It doens't even have to be a dramatic meeting... the point is to assign roles. I always make sure that I know (and by extension, they KNOW I KNOW) who is running the resus (ME!), who has airway, who is procedure person #1, procedure person #2, which nurse is recording, which nurse is starting ivs, which nurse sets up monitor, which nurse gets drugs... etc. Of course, with less nurses one person might end up doing two things, but the point is that every one has an assigned role so that things move calmly and efficiency.

The second point is something I have found really settles a room and allows the controlled silence. As soon as EMS enters with the patient, I address them and say "Hi, I'm Dr. Bulgethetwine, I'm running the resus, so please talk to me". I bet the EMS folk would say they like it because they've just walked into a room with upwards of 10 people, and at least they now know who to address their monologue to.

I'm sure you're gonna more feedback soon!
 
Please tell me this didn't occur at my hospital because we are assigned roles. Usually things are fairly calm and only the leader should speak. If people in the peanut gallery or others start talking, then it gets to where the team leader can't talk in a normal tone and give orders or announce findings. This is where the team leader (or the attending trauma surgeon) tells the people in the peanut gallery to STFU or get out of the bay. (We have a designated red line in our trauma bay where anyone behind it has to remain quiet and is there only as an observer; only those with assigned roles are allowed "in the box.")

Normally things go fairly smoothly, but anytime a patient gets their chest cracked in the ED, it can get rowdy no matter where you're at. I know you work in my area, which is why I asked if this happened at Yale. However, I wouldn't think it would since our airway equipment is already set up beforehand (unless a senior resident didn't check it off) and everyone has assigned roles.

By the way, the person who put in the chest tube is NOT responsible for setting up the Atrium/Pleuravac. That role is designated to a specific nurse. Trauma patients that need chest tube usually need them urgently, and the person placing the tube doesn't have the time to set up the Atrium. That's supposed to happen while the chest tube is being placed.
 
southerndoc said:
Please tell me this didn't occur at my hospital
Click to expand...

Nah. I work up in Hartford. We've got 2 major hospitals here that we usually use, suffice to say it was one of those two.

Your setup, and especially that bit about the red line sounds like something this hospital should really consider. No way a normal tone of voice would be heard at all in this trauma room.

Excuse my ignorance about the roles involved with setting up chest tubes, etc. Still, what should have happened didnt -- not just with this example but seemingly with a number of things. You shoulda seen it.
 
fiznat said:
Nah. I work up in Hartford. We've got 2 major hospitals here that we usually use, suffice to say it was one of those two.

Your setup, and especially that bit about the red line sounds like something this hospital should really consider. No way a normal tone of voice would be heard at all in this trauma room.

Excuse my ignorance about the roles involved with setting up chest tubes, etc. Still, what should have happened didnt -- not just with this example but seemingly with a number of things. You shoulda seen it.
Click to expand...

I probably have an idea of which of the two. I know you work in the Hartford area, but I also know that you occasionally transport patients to us. I was praying that it wasn't Yale considering how well organized most of the trauma resuscitations (and medical resucitations) are usually done.

Before one particular member gets upset, I'm not being self-righteous about how we handle major resuscitations.
 
Chuck Norris would have cracked the chest barehanded, and the only bags of blood falling on the floor would have been the lifeless people who recieved roundhouse kicks to their skulls.
 
I just finished a rotation at a mega-trauma hospital (by that I mean the major trauma center for a 1 million plus city with some "trauma-rich" areas) and there was a significant variability in the way traumas went. On the whole, there were always too many people, and not enough communication b/t EM and Trauma services. So many times EM is on primary survey and Trauma is trying to roll the patient. However, the worst problems occured when we had 3+ traumas roll in within 5 minutes of one another. This was, by the way, not an uncommon occurence. Reason being that by the time the 3rd trauma came in, the trauma RNs were all tied up, the 2nd and 3rd year residents were already in a trauma, so the trauma feel to first year EM or attending, neither of which, for their own reasons, were thrilled about running the trauma, and therefore just kind of let the ship sail itself.
 
ElZorro said:
I just finished a rotation at a mega-trauma hospital (by that I mean the major trauma center for a 1 million plus city with some "trauma-rich" areas) and there was a significant variability in the way traumas went. On the whole, there were always too many people, and not enough communication b/t EM and Trauma services. So many times EM is on primary survey and Trauma is trying to roll the patient. However, the worst problems occured when we had 3+ traumas roll in within 5 minutes of one another. This was, by the way, not an uncommon occurence. Reason being that by the time the 3rd trauma came in, the trauma RNs were all tied up, the 2nd and 3rd year residents were already in a trauma, so the trauma feel to first year EM or attending, neither of which, for their own reasons, were thrilled about running the trauma, and therefore just kind of let the ship sail itself.
Click to expand...

ELZorro, I have seen the same thing happen here at UT-Houston / Memorial-Hermann. We are the nations busiest level 1 in terms of acuity. The VAST majority of the time the major traumas run like a well-oiled machine, with everyone in their pre-assigned roles (we do it so much there is no need for a pre-arrival conference). We even have a big poster on the wall which tells where everyone should stand during the initial resus (EM at the head of the bed BTW).

However, on an extremely busy night in my first month, when 4 MAJOR traumas came in virtually at once, the last one was run by me, a nurse, and a nursing student for a few minutes until the attending came in to check on things. Everything turned out OK, I learned a great deal; but I assure you it was no well oiled machine at that point (mostly my fault).

It is also common at our institution for the nurse to set up the pleuravac, and the MD to insert the chest tube. You can always wait awhile for the setup, the tube decompression is the important part.

As a previous poster mentioned, everything gets a little hectic when chests are cracked in the ED, even here when we do it 1-2 times a month.
 
Okay, I know this post is more geared toward the hospital's response to the situation, but I have a quick question about some of the EMS treatment. Why did the medic in the field decompress the chest at all, let alone twice? If the guy has 4 bullet holes in his back, and 4 more exit wounds, the guy has 8 pretty big holes in his thorax. The guy already had his chest decompressed 8 times, two more little needle holes aren't going to do much more. Dressing the wounds with occlusive dressing and leaving one corner flapped performs the pressure release function of the needle decompression in a closed tension pneumothorax. My question is: was this an overzealous paramedic using one too many tricks, or did I miss a CE and decompressing open chest wounds is now the way to go?
 
greytmedic said:
Okay, I know this post is more geared toward the hospital's response to the situation, but I have a quick question about some of the EMS treatment. Why did the medic in the field decompress the chest at all, let alone twice? If the guy has 4 bullet holes in his back, and 4 more exit wounds, the guy has 8 pretty big holes in his thorax. The guy already had his chest decompressed 8 times, two more little needle holes aren't going to do much more. Dressing the wounds with occlusive dressing and leaving one corner flapped performs the pressure release function of the needle decompression in a closed tension pneumothorax. My question is: was this an overzealous paramedic using one too many tricks, or did I miss a CE and decompressing open chest wounds is now the way to go?
Click to expand...

Our protocols (back in my medic days) had bilateral needle decompression for traumatic arrests. Now, this wasn't an arrest, but I understand the idea. Likewise, the locations for chest tubes and needle decompression are there for a reason, versus the haphazard location of bullet holes. I understand what you mean about the patient having "had his chest decompressed 8 times", but those holes may or may not treat the same condition they caused.

If I was medical director, I would be on the medic's side.
 
I have been involved in many traumas. The ones who aren't very sick generally run very orderly and calmly. As the patients get sicker, the adrenaline of the health care workers ramps up. As a rule, all very sick trauma codes are a cluster. I frequently put in chest tubes before the pleurivac is set up (doesn't matter, patient is usually getting positive pressure ventilation by then). The nurses cannot do anything instantaneously so there is always some yelling for something stat, especially when the patient is so sick he's getting a thoracotomy.

You're telling me in 10 minutes this patient got lines, chest tubes, an ED thoracotomy and was still alive enough to go to the OR. 10 minutes! That's fantastic! Helluva great trauma code! Next you're going to tell me this guy actually lived, and you're criticizing this trauma team? Sure, we'd all like to be polite and have every thing run very smoothly, but I got news for you, nobody does ED thoracotomies every day so it is never going to be smooth.

Clearly there is something to be said for having a designated leader, being ready to go when the patient gets there, a good relationship between trauma surgery and EM etc, but I challenge all of you to think of a patient who got an ED thoracotomy and was alive in the OR 10 minutes after arrival. Remember the pool of blood on the floor? Remember how it took 3 custodians two hours to clean up the mess before you got the trauma bay back? Now tell me that a bystanding paramedic who had never seen an ED thoracotomy before (granted, I'm making an assumption, forgive me if its wrong) wouldn't describe the whole scene as a cluster.

That said, trauma codes used to be videorecorded and reviewed later in trauma conferences. Too bad the medicolegal environment makes this rare anymore.
 
Having seen quite a few traumas recently, I can understand how an outsider would think it just one big cluster ****. It really only appears that way because there are so many people running around doing different things. In an ideal situation, all the needed supplies are gathered before arrival and everyone in the room is experienced as to their specific role.

Again, this is an ideal situation unencumbered by untrained residents, nurses and medical students. I mean let's face it, how many times have you looked up from a trauma and every single person in ER is w/i 10 feet of the trauma pt. Overcrowding only adds to the apearance of confusion.

JJ
 
Oh, we still record everything. When I stock the trauma room, I try not to be talking to anybody, because motion or noise will start the recorder.

We don't have a red line on the floor, but we have a locked room that nobody needs to be in unless there's an acute case. If you're not trained on what to do while in the room, your ID badge won't open the door.

We also have specific people pre-assigned to roles. One pit boss PGY-3, one staff doc to supervise, a PGY-2 if procedures need to be done (like that chest tube), two nurses, one tech (to run the phones, put blood in lab tubes, and order stuff as the proxy for the pit boss). All the preceding people wear a pager and come running when it goes off... although we typically have from 3 to 15 minutes' warning before a case. Recording is done by rotating med students.

The only people I need to get on the overhead and page for are the students. Everyone else is there and waiting. I have the ultrasound located, plugged in, and running. The RNs have warm fluids within arm's reach and their bucket o' meds ready. And most importantly, everyone knows what they're supposed to do.

When we get 3 or 4 cases at once, it stretches pretty thin, it's true, but the RN's and the techs know who's next in line to take the role for the next case. Clerks jump in and record when we run out of students. And when things are really nuts, with EMS and research peeps and curious staff milling around, the charge RN du jour has been known to stand in the middle of the room and shout, "anybody in here who does not have a specific task to do needs to get the &#%@ out!"
 
Nothing like watching Dr. Duke calmly give orders from his red-outlined footprints at the foot of the bed and a few choice, "Boy, if you don't get that chest tube in the next few minutes, I may have to light a fire under your a**".

I had a few slow nights on my neurosurgery rotation at Hermann and I got to watch him work. Having worked EMS for awhile before that I was very surprised at how smoothly things ran.

-Mike


EM Junkie said:
ELZorro, I have seen the same thing happen here at UT-Houston / Memorial-Hermann. We are the nations busiest level 1 in terms of acuity. The VAST majority of the time the major traumas run like a well-oiled machine, with everyone in their pre-assigned roles (we do it so much there is no need for a pre-arrival conference). We even have a big poster on the wall which tells where everyone should stand during the initial resus (EM at the head of the bed BTW).

However, on an extremely busy night in my first month, when 4 MAJOR traumas came in virtually at once, the last one was run by me, a nurse, and a nursing student for a few minutes until the attending came in to check on things. Everything turned out OK, I learned a great deal; but I assure you it was no well oiled machine at that point (mostly my fault).

It is also common at our institution for the nurse to set up the pleuravac, and the MD to insert the chest tube. You can always wait awhile for the setup, the tube decompression is the important part.

As a previous poster mentioned, everything gets a little hectic when chests are cracked in the ED, even here when we do it 1-2 times a month.
Click to expand...
 
I work (as a tech) at a somewhat small community ED/trauma center (55-60,000 cases/year?) -- seeing 5 or 6 traumas a week, maybe. Anyway, per trauma we always have 3-4 nurses, respiratory, surgery resident, IV therapy, 1-2 techs, and one of our attending EPs. It does get pretty wild. There are always 2-3 hands per syringe, which equates 2-3 people trying to do one thing.

My hospital uses us techs quite liberally, and we're part of the "trauma team." We remove clothing, put them on the monitor, foley if pelvis cleared, EKG if indicated, and overall trauma prep before arrival (spike bags, get leads ready, make sure everyone has gowns and shields, get appropriate airway gear together, make sure US nearby, x-ray notified). We're also bed-pushers, wound irrigators, board pullers, c-spine holders, and we suction up some nasty ****.

It does get crazy in those rooms, though.
 
Febrifuge said:
When we get 3 or 4 cases at once, it stretches pretty thin, it's true, but the RN's and the techs know who's next in line to take the role for the next case. Clerks jump in and record when we run out of students. And when things are really nuts, with EMS and research peeps and curious staff milling around, the charge RN du jour has been known to stand in the middle of the room and shout, "anybody in here who does not have a specific task to do needs to get the &#%@ out!"
Click to expand...

That's my kind of nurse!

Seriously, I saw a very similar thing happen with a "routine" chest tube gone south in an ICU. When the procedure was going on it was Surg Cheif Resident, Surg Intermediate Resident, M4, and RN with me in the corner allowed to watch.

I swear something about that lady's falling O2 sats attracted people like flies to feces. By the time she hit 60s the whole room was PACKED with people, I squeezed out and made myself scarce. From a distance I could see that EVERYONE from the ICU (RNs, RTs, PCTs, CNAs!!!) were running over to see the action.

At some point in the future I will probably run codes, hopefully traumas as well. I plan on being one of those people that says "if you don't have a specific job, leave, if you have information to report, report it to me."
 
Chronic Student said:
Nothing like watching Dr. Duke calmly give orders from his red-outlined footprints at the foot of the bed and a few choice, "Boy, if you don't get that chest tube in the next few minutes, I may have to light a fire under your a**".

I had a few slow nights on my neurosurgery rotation at Hermann and I got to watch him work. Having worked EMS for awhile before that I was very surprised at how smoothly things ran.

-Mike
Click to expand...

Don't forget the occasional "God damnit what the hell are ya'll up to in here?"
 
NinerNiner999 said:
Chuck Norris would have cracked the chest barehanded, and the only bags of blood falling on the floor would have been the lifeless people who recieved roundhouse kicks to their skulls.
Click to expand...
He obviously trained under Ken Mattox. :meanie:
 
greytmedic said:
Okay, I know this post is more geared toward the hospital's response to the situation, but I have a quick question about some of the EMS treatment. Why did the medic in the field decompress the chest at all, let alone twice? If the guy has 4 bullet holes in his back, and 4 more exit wounds, the guy has 8 pretty big holes in his thorax. The guy already had his chest decompressed 8 times, two more little needle holes aren't going to do much more. Dressing the wounds with occlusive dressing and leaving one corner flapped performs the pressure release function of the needle decompression in a closed tension pneumothorax. My question is: was this an overzealous paramedic using one too many tricks, or did I miss a CE and decompressing open chest wounds is now the way to go?
Click to expand...
I wouldn't ream the medic's butt if I were the MD, but I certainly wouldn't laud them for it. A polite explanation (ala BKN's post a while back about needle thoracostomies) would be in line however.
 
fiznat said:
Hey guys-- been a while since I've posted here. This is something I posted on an EMS forum I frequent, but I thought it would be interesting to see what you guys have to say about it as well. Please forgive what may be lost in the translation between EMS and ED, but I think the point is fairly clear.

....

I was in the ED today dropping off a patient when I overheard a patch on the c-med radio saying that a trauma was coming in. ...GSW, 4 shots from a handgun into the patient's back, through the torso, and 4 exit wounds out the chest. You can hear yelling from the back of the rig as the driver is giving the patch, he reports that the patient cannot move his legs and is beginning to become combative as the hypoxia and blood loss begin to take hold.

The crew did a good job. The patient was spine-neck immobilized, the chest twice decompressed, IV established with fluids running, O2 provided along with assisted vents via BVM. Sinus tach on the monitor, and the little bleeding seemed to be well controlled. ...All this performed with a combative patient and --as I was told later-- a group of rowdy onlookers on-scene. It wasnt until they rolled into the trauma room that the chaos began to ensue.

Seriously the worst cluster I have ever seen. Had to be 15 ED docs, nurses and techs cramped into a trauma room designed for probably half that. Immediately people start yelling. "Get me gloves!" "Get this guy tubed NOW!" "Give me a blade! Give me a blade! Give me a blade!" People are pushing each other out of the way, lines are crossed and steps are missed. I watch a resident insert a chest tube and then - once its inserted - look around and wonder where the rest of his equipment was. He didnt set it up before cutting, so he starts yelling for it. Nobody gets any respect. Nurses are treated like idiots because they dont instantly provide equipment to doctors, techs are pushed out of the way as they struggle to help. Everybody is yelling.

By the time it was said and done, this patient got his chest cracked right in the bay, tubes inserted and lines of blood run. Probably 10 minutes in the trauma bay and he was rushed up to the OR. As the bed was rushed out of the room, the femoral line almost gets pulled out as the bags of blood fall to the floor. Someone gets knocked down.

I have never ever seen such horrible communication and teamwork before. This was not a trauma team, as the called for on the intercom, it was a collection of bigheaded doctors and angry nurses-- each screaming to have their voice heard over the chaos.

I've seen this trauma team work patients before, but not like this. Usually it is a moderate trauma -- an MVA or a fall. This GSW was one of those rare and fantastic traumas: the kind you get to pull all the tricks and procedures out for. Hell, the medic got to decompress the guy in the field -- twice! How often does that happen, right? ...But the rarity of it and the added stress seemed to take the trauma team and fracture it. What is normally a cohesive team performing organized assessment and treatment became a frantic collection of angry demands and rushed decisions. Not exactly what you would hope for if you were that poor patient on the stretcher.

Anyone ever seen this before? How does your ED trauma team work? Do you find that doctors tend to yell over the crowd as the issue demands, or is there actual calm collected teamwork? ...Even on the bad traumas? I know we struggle with this all the time in the field-- and I'm sure most of us are familiar with that whipped-up exciting urgency that can sometimes become overpowering on the really bad calls.... but we all consider it to be the mark of a good medic/EMT/firefighter to be able to rise above the chaos and organize. It bothers me that these (mostly) experienced ED physicians found this basic principle so difficult to achieve.

I have 5 years of experience in EMS as an EMT and now (almost! haha) a medic, but I have never seen this kind of frantic response before from an ED trauma team. I know this is a long post and a long story (I tried to make it interesting), but I'm interested to hear other people's observations of bad traumas run in the ED. Whats the best youve seen? The worst?
Click to expand...
My final comment for now, a quote from one of the military EM docs I worked with "Ain't no clusterf--k like a military trauma code." Zero went right on the case that provoked that comment, mostly due to the rank structure involved. The multiple stab wounds, the failure of the surgeons to respond in a timely manner and the FP residents and med students not getting out of the way when they were told to do so by the EM attending only compounded the issues.....
 
Many GSWs are not a clean punched-out hole that stays patent after the bullet passes through. There's often a fairly small wound tract that allows the wound to close back up. An indication for needle thoracostomy is a developing tension pneumothorax, which certainly sounds plausible in this case. The guy did wind up needing chest tubes, so it sounds like the medic was on solid ground on this one.

greytmedic said:
The guy already had his chest decompressed 8 times, two more little needle holes aren't going to do much more....My question is: was this an overzealous paramedic using one too many tricks, or did I miss a CE and decompressing open chest wounds is now the way to go?
Click to expand...
 
bartleby said:
Many GSWs are not a clean punched-out hole that stays patent after the bullet passes through. There's often a fairly small wound tract that allows the wound to close back up. An indication for needle thoracostomy is a developing tension pneumothorax, which certainly sounds plausible in this case. The guy did wind up needing chest tubes, so it sounds like the medic was on solid ground on this one.
Click to expand...
Seems like I lucked out then.....my GSW scar is a perfectly round little white mark on my right pec. :meanie:
 
And if you keep speaking on sensitive areas, you'll have about 50 more from gun-toting pre-meds.
 
Pose said:
And if you keep speaking on sensitive areas, you'll have about 50 more from gun-toting pre-meds.
Click to expand...

Now Dropkick, play nice with the little ones. :laugh:
 
Pose said:
And if you keep speaking on sensitive areas, you'll have about 50 more from gun-toting pre-meds.
Click to expand...

DKM, better lay low for awhile. :meanie:
 
I am not saying the paramedics did harm or made anything worse with the needle decompressions, but was it necessary to put two more holes in the patients chest? I know that none of us were actually on the call and hindsight is 20/20, but from what I have been taught, read, and experienced needle decompressions in an open chest wound don't really do much. If the wounds were communicating pneumothoraxes any air that would enter through those holes would also be able to get out those holes. This is were the occlussive dressing with the flutter valve comes in. Now I admit that it can be a pain in the arse to get an occlussive dressing to stick to a blood covered chest, even the commercial chest dressing don't always work great, but they would prevent air coming in the hole and allow excess positive pressure in the chest to escape. If the patient developed a tension pneumothorax the air bubbles would rise to the highest point. If the pt was secured to a backboard, the top of the chest(probably were the exit wounds were) would be the highest point. I know in closed tension pneumo's it is a different story and decompressions are quite valuable, but I am interested in the classic "sucking chest wound" situation. Now in my system we do bilateral needle decompressions on traumatic arrests and a needle decompression of a closed pneumothorax requires explicit medical control approval, but these are closed pneumo's with no way of the excess pressure from escaping. This patient had 8 holes in his chest so the two needle holes probably aren't going to be the cause of death and the risks are minimal in this case, but if you had a patient with just one chest wound that was obivously communicating with the external atmosphere would you needle decompress or go straight to the chest tube? EMS folks, do your protocols allow for needle decompression of open chest wounds before medical control contact and if not what is the PMD's reasoning? And ER docs, would you authorize needle decompressions in the field for an open chest wound or tell the ambulance to drive faster? Just curious since I have only worked in locations with low crime rate and I have only had a couple of patients with open chest wounds and none of them developed signs of tension pneumo's just using the occlusive dressing.
 
greytmedic said:
I am not saying the paramedics did harm or made anything worse with the needle decompressions, but was it necessary to put two more holes in the patients chest? I know that none of us were actually on the call and hindsight is 20/20, but from what I have been taught, read, and experienced needle decompressions in an open chest wound don't really do much. If the wounds were communicating pneumothoraxes any air that would enter through those holes would also be able to get out those holes. This is were the occlussive dressing with the flutter valve comes in. Now I admit that it can be a pain in the arse to get an occlussive dressing to stick to a blood covered chest, even the commercial chest dressing don't always work great, but they would prevent air coming in the hole and allow excess positive pressure in the chest to escape. If the patient developed a tension pneumothorax the air bubbles would rise to the highest point. If the pt was secured to a backboard, the top of the chest(probably were the exit wounds were) would be the highest point. I know in closed tension pneumo's it is a different story and decompressions are quite valuable, but I am interested in the classic "sucking chest wound" situation. Now in my system we do bilateral needle decompressions on traumatic arrests and a needle decompression of a closed pneumothorax requires explicit medical control approval, but these are closed pneumo's with no way of the excess pressure from escaping. This patient had 8 holes in his chest so the two needle holes probably aren't going to be the cause of death and the risks are minimal in this case, but if you had a patient with just one chest wound that was obivously communicating with the external atmosphere would you needle decompress or go straight to the chest tube? EMS folks, do your protocols allow for needle decompression of open chest wounds before medical control contact and if not what is the PMD's reasoning? And ER docs, would you authorize needle decompressions in the field for an open chest wound or tell the ambulance to drive faster? Just curious since I have only worked in locations with low crime rate and I have only had a couple of patients with open chest wounds and none of them developed signs of tension pneumo's just using the occlusive dressing.
Click to expand...

My system allows needle decompression without contacting medical control in trauma patients. Whether or not I would choose to do so in an open chest wound would depend on 1) does the patient have breath sounds and 2) how sick is the patient 3) how far away are we from a trauma center?

If I had a patient who was riddled with bullet wounds, with no breath sounds, and crashing (unconsicous, tachycardic, hypotensive, horrible O2 sats) even though I would guess that his problem was either massive hemothorax, cardiac injury, great vessle rupture etc, I would still decompress on the off chance that he has a little pocket of trapped air that if relieved would buy us enough time to reach a hospital.
 
Trauma is a joke. Everybody and their brother wants in on the action. I was rotating on my IM service admitting someone from the ER when a trauma came in and literally teh ENTIRE ER STAFF ran over to the trauma bay to try to get their hands dirty. Hell I even saw the freakin janitor make his way over there.
 
sphincter tone said:
If I had a patient who was riddled with bullet wounds, with no breath sounds, and crashing (unconsicous, tachycardic, hypotensive, horrible O2 sats) .
Click to expand...

Amen.

Nobody is going to criticize you for needling a guy with multiple GSWs to the chest. It isn't like he isn't going to get a chest tube anyway.
 
MacGyver said:
Trauma is a joke. Everybody and their brother wants in on the action. I was rotating on my IM service admitting someone from the ER when a trauma came in and literally teh ENTIRE ER STAFF ran over to the trauma bay to try to get their hands dirty. Hell I even saw the freakin janitor make his way over there.
Click to expand...


Don't you have other things to do than troll? I would assume that being an idiot is a fulltime job for you.

mike
 
greytmedic said:
was it necessary to put two more holes in the patients chest?
Click to expand...

It basically comes down to: the guy didnt have breath sounds before decompressing, and he did afterwards. ...At least for a little while, until the cavity filled up with blood.

As far as the sucking chest wound question, we use 3-way valves on top of the decompression catheter so that the pressure can be relieved every so often (and then locked down) without allowing a pathway for air to enter back into the chest.

Like "sphincter tone" said (who doesnt work in my area I dont think), we have standing orders for this type of procedure given this kind of presentation. Regardless of how many holes are already in the chest, if there is reason to believe a pneumo/hemo is obstructing the patient from getting air then we are going to decompress the chest. The two tiny holes made by sterile needles are the least of this patient's problems. No airway pretty much trumps anything else.



Very true that my observation of the way this trauma was run may have been a complete misunderstanding. I admit that I am not completely familiar with the delegation of tasks nor the proper chain of command that is supposed to be followed. Still, I think I know a cluster when I see one. Lines are not supposed to be almost pulled out, people are not supposed to get knocked down, and yelling frantically seems like a less than optimal way to get things done. I'm willing to admit my ignorance on the details here, but I think anyone here would have said the same about the way this case was run. I'm "just" a paramedic right now, but give me the benefit of the doubt on this one.
 
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