GonnaBeADoc2222

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Just wondering how y'all handle blunt trauma at your shops. I find that as I've become more senior in residency and am preparing for first year of attendinghood next year, I've become increasingly conservative, especially when it comes to trauma. Unless someone has a very non-concerning mechanism (fall from standing with no head trauma, fall off slow moving bicycle, fall down a few steps), is a good historian, is not intoxicated, is not elderly (i.e. osteopenic), not anti-coagulated...they are usually getting a pan-scan from me. I've just found too many things over my few years that I wasn't expecting to find (multiple rib fractures not detected on CXR (sometimes with small pneumothoraces), small splenic lacerations, small pulmonary contusions). Lots of these things likely won't end up being clinically relevant, however I think it's good for me / the patient to know that they are present and for them to get follow up for them / possible 1 night observation admission. There are times when I am on the fence and feel bad doing this. Another possible pathway is 3-5 hours of observation in the ED, serial FAST and serial physical exams. However, when I am managing 15 beds this just isn't possible.
 

gro2001

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Just wondering how y'all handle blunt trauma at your shops. I find that as I've become more senior in residency and am preparing for first year of attendinghood next year, I've become increasingly conservative, especially when it comes to trauma. Unless someone has a very non-concerning mechanism (fall from standing with no head trauma, fall off slow moving bicycle, fall down a few steps), is a good historian, is not intoxicated, is not elderly (i.e. osteopenic), not anti-coagulated...they are usually getting a pan-scan from me. I've just found too many things over my few years that I wasn't expecting to find (multiple rib fractures not detected on CXR (sometimes with small pneumothoraces), small splenic lacerations, small pulmonary contusions). Lots of these things likely won't end up being clinically relevant, however I think it's good for me / the patient to know that they are present and for them to get follow up for them / possible 1 night observation admission. There are times when I am on the fence and feel bad doing this. Another possible pathway is 3-5 hours of observation in the ED, serial FAST and serial physical exams. However, when I am managing 15 beds this just isn't possible.
Don't feel bad. Trauma is a leading cause of death for young people. And we all know how sneaky old people can be at hiding injuries. There are plenty of potentially bad injuries that are often missed by exam/vitals, especially early on. When in doubt, scan.

The more challenging thing for me was deciding what to do with someone who had a terrifying mechanism but despite pan scanning I have not found a specific injury worth admitting. I used to feel funny about admitting them for observation. I don't anymore.
 

WilcoWorld

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Can you use an exam and/or clinical decision rule to rule out significant injury? If so use it.

If you can not examine a body part (you can't get a reliable belly exam in an intubated patient), or if your clinical decision rule fails, image the body part.

A lot depends on what your trauma service is comfortable with and what your hospital can accommodate.

At a hospital that was always out of beds with a Trauma service that spends all night in the OR (CHIraq) we scanned based on mechanism.
At a hospital where we usually had beds, and the Trauma service could do serial belly exams, we only scanned intubated patients or those with a concerning physical exam.
 

WilcoWorld

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Also, gotta be a bugaboo about the FAST - it is widely misunderstood.

The FAST exam is for determining if hemodynamic instability is due to an injury that will benefit from an emergent surgical procedure (laparotomy or a pericardial window).

The FAST exam is NOT for determining if a patient needs a scan. Please educate me if I've missed some good literature on this, but I do not see a role for serial FAST exams.

Serial belly exams are one of the best tests in medicine whereas serial FAST exams are good for resident education, and not much else.
 

UKEMdoc

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In ten years I can't think of a time when an abdo FAST scan changed our management plan on a trauma. They were usually stable enough for CT, in the handful who needed the OR straight off the source of bleeding was pretty obvious
 
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TimesNewRoman

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In ten years I can't think of a time when an abdo FAST scan changed our management plan on a trauma. They were usually stable enough for CT, in the handful who needed the OR straight off the source of bleeding was pretty obvious
Really? Boarderline BP or a little tachy with positive fast --> OR. Also helps surgeon decide which cavity to enter first.
 

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Really? Boarderline BP or a little tachy with positive fast --> OR. Also helps surgeon decide which cavity to enter first.
For the record, this doesn't happen in the real world. They still want the CT. Every time. And they'll tell you its so they "know where to look". As in, spleen vs liver vs something else.
Drives me up the wall.
 
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TimesNewRoman

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For the record, this doesn't happen in the real world. They still want the CT. Every time. And they'll tell you its so they "know where to look". As in, spleen vs liver vs something else.
Drives me up the wall.
I know this doesn't happene everywhere, but saying it doesn't happen anywhere outside of academia is a bit of an overstatement.
 

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I know this doesn't happene everywhere, but saying it doesn't happen anywhere outside of academia is a bit of an overstatement.
N=5 community hospitals for me, all of them do it. And even at the academic site I used to work at they did it. I'm sorry, but in the real world, US just isn't used like it is at the training sites. And you know what else, while it might make dispos faster in an academic setting, it often slows them down in the community.
I've been at 4 different academic sites as well.
 

GeneralVeers

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Our trauma surgeons scan everyone head to toe, regardless of mechanism or injury. It's due to "we don't want to miss anything". I got referred to the medical staff review on a 20 year old patient in rollover MVA with ONLY complaint of back pain and T10 compression fracture. He wasn't drunk and in minimal distress so I could get a good exam. The complaint was I didn't "pan scan due to mechanism".
 
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EM4life

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I work at 4 different community EDs as apart of my practice. Coming from a trauma center where the standard was to panscan everyone, I can definitively say I have never pan scanned anyone since being out of residency. Not because some people don't warrant it, but if there is significant trauma, abnormal vitals, abnormal CXR, etc, it justifies an immediate transfer to the trauma center. These are not people you want decompensating in your CT scanner with no surgeon in sight.
 
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GonnaBeADoc2222

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Also, gotta be a bugaboo about the FAST - it is widely misunderstood.

The FAST exam is for determining if hemodynamic instability is due to an injury that will benefit from an emergent surgical procedure (laparotomy or a pericardial window).

The FAST exam is NOT for determining if a patient needs a scan. Please educate me if I've missed some good literature on this, but I do not see a role for serial FAST exams.

Serial belly exams are one of the best tests in medicine whereas serial FAST exams are good for resident education, and not much else.
Agree 100% Can't tell you how many FASTs I've had to do on people who fell down 3 stairs 5 hours ago and have normal vitals.

I work at 4 different community EDs as apart of my practice. Coming from a trauma center where the standard was to panscan everyone, I can definitively say I have never pan scanned anyone since being out of residency. Not because some people don't warrant it, but if there is significant trauma, abnormal vitals, abnormal CXR, etc, it justifies an immediate transfer to the trauma center. These are not people you want decompensating in your CT scanner with no surgeon in sight.
Also agree with this. The [pre-transfer] things I don't understand are scanning the chest but not the belly, or scanning the head but not the c-spine but sending the patient in a collar.
 

emergentmd

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Our trauma surgeons scan everyone head to toe, regardless of mechanism or injury. It's due to "we don't want to miss anything". I got referred to the medical staff review on a 20 year old patient in rollover MVA with ONLY complaint of back pain and T10 compression fracture. He wasn't drunk and in minimal distress so I could get a good exam. The complaint was I didn't "pan scan due to mechanism".
HOLD on...... you are going to be beaten up by all of the residents and academics that you are not a good doctor. How dare you scan everything and irradiate them?

If you are confused, read the diverticulitis thread.
 
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dpmd

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Really? Boarderline BP or a little tachy with positive fast --> OR. Also helps surgeon decide which cavity to enter first.
For the record, this doesn't happen in the real world. They still want the CT. Every time. And they'll tell you its so they "know where to look". As in, spleen vs liver vs something else.
Drives me up the wall.
Well, if they are just a little tachy or have a borderline BP without peritonitis with a positive belly FAST, I am going to want the scan because if there is a liver or spleen injury they might get IR or admission with serial belly exams to see if they declare a bowel injury. Not every spleen needs to go in the bucket and not every liver needs the OR.
 

dpmd

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Our trauma surgeons scan everyone head to toe, regardless of mechanism or injury. It's due to "we don't want to miss anything". I got referred to the medical staff review on a 20 year old patient in rollover MVA with ONLY complaint of back pain and T10 compression fracture. He wasn't drunk and in minimal distress so I could get a good exam. The complaint was I didn't "pan scan due to mechanism".
Well, to be fair it takes a heck of a lot of force to fracture the spine of a young adult which can lead to other injuries that wouldn't necessarily declare themselves immediately. How long did you watch him before letting him go home?
 

Tiger26

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Having done an ultrasound fellowship and now working in the community 80% of the time and a major academic trauma center the other 20%, I bet I do 1-2 fasts a year on the off chance that they will change management. In the community (level 3) probably 99% of patients are stable enough to go to CT for a definitive diagnosis.

One of the biggest fallacies in EM and ultrasound is that the FAST can be used for ruling out an injury.
1) It takes quite a bit of blood to even show up on FAST
2) It's only helpful in the unstable patient where you have a high pre-test suspicion for an intra-abdominal source
 

Dr.McNinja

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Well, if they are just a little tachy or have a borderline BP without peritonitis with a positive belly FAST, I am going to want the scan because if there is a liver or spleen injury they might get IR or admission with serial belly exams to see if they declare a bowel injury. Not every spleen needs to go in the bucket and not every liver needs the OR.
I don't disagree with this at all. It's when they're clearly hypotensive with a positive fast, and then we resuscitate them to go to CT instead of the OR that annoys me and kills patients.
 
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dpmd

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I don't disagree with this at all. It's when they're clearly hypotensive with a positive fast, and then we resuscitate them to go to CT instead of the OR that annoys me and kills patients.
That is a different story (scanning the patient who I already decided needed a surgery is something I have only done on occasion and was more for stuff like the head in a patient that got stable-ish enough that I thought we could run through the scanner while waiting for the team to come in from home-because at night our OR teams had a 30 minute response allowed)
 

WilcoWorld

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Our trauma surgeons scan everyone head to toe, regardless of mechanism or injury. It's due to "we don't want to miss anything". I got referred to the medical staff review on a 20 year old patient in rollover MVA with ONLY complaint of back pain and T10 compression fracture. He wasn't drunk and in minimal distress so I could get a good exam. The complaint was I didn't "pan scan due to mechanism".
Ridiculous. Did you even miss anything?
 

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My latest beef is with our "level 2s". Where I see them first and order my work up. The trauma pas come down and add on ridiculous X-rays. If theirs a scratch on an extremity, it gets an X-ray. I get ready to dc a lot of these patients and the nurse says "do you wanna wait on that hand X-ray?"
 

TooMuchResearch

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Agree 100% Can't tell you how many FASTs I've had to do on people who fell down 3 stairs 5 hours ago and have normal vitals.



Also agree with this. The [pre-transfer] things I don't understand are scanning the chest but not the belly, or scanning the head but not the c-spine but sending the patient in a collar.
When my attending asks if I'm doing a FAST on these people, I tell them no because it won't change management. Nearly all of them say okay.

Are you doing a FAST?
No, they have belly tenderness with normal vitals. They get CT.

Are you doing a FAST?
No, the belly doesn't hurt.

Are you doing a FAST?
What? I already have the read back on CT.
 

mestielest

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In my current hospital (50 000 pop -county state hosp), me(uro attending) and a gen surgeon are on charge everytime. We do not have CT, we have USG on-call. Our emergency service is run by family docs who are in theirs first years of practice.

In an unstable patient and abdominal wounds(sharp or bullet), we make an emergency exploration every time. Most of the times we do not even wait the result of CBC. I think FAST or CT would not change our practice in this situation. We do not have a neurosurgeon or thoracic surg in our hospital, therefore we use air transfer for open head wounds. For thoracic injuries, gen surgeon inserts the thoracic tube; major heart or aortic injuries are mostly lost before they reach to hospital.

But in blunt injuries, without a clear history(single living), car accidents(because people tend to canalize emergency docs to their loved ones and do not feel theirself injured with the heat of the event) etc. a pan-scan is very required for us. I dont know how much it changes the management strategy but I assure that it changes very much the stress over the physician. Therefore feel happy to order a pan-scan in a blunt, up to intermediate trauma or everyone who has found by someone.

Take care...
 

engineeredout

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Just wondering how y'all handle blunt trauma at your shops. I find that as I've become more senior in residency and am preparing for first year of attendinghood next year, I've become increasingly conservative, especially when it comes to trauma. Unless someone has a very non-concerning mechanism (fall from standing with no head trauma, fall off slow moving bicycle, fall down a few steps), is a good historian, is not intoxicated, is not elderly (i.e. osteopenic), not anti-coagulated...they are usually getting a pan-scan from me. I've just found too many things over my few years that I wasn't expecting to find (multiple rib fractures not detected on CXR (sometimes with small pneumothoraces), small splenic lacerations, small pulmonary contusions). Lots of these things likely won't end up being clinically relevant, however I think it's good for me / the patient to know that they are present and for them to get follow up for them / possible 1 night observation admission. There are times when I am on the fence and feel bad doing this. Another possible pathway is 3-5 hours of observation in the ED, serial FAST and serial physical exams. However, when I am managing 15 beds this just isn't possible.
I feel you. In general I like to think that I am not a super orderer of tests, but god damn I've found traumatic injuries I never expected to find, and it makes me want to image everyone.

If there is one thing I learned on my (pretty worthless) trauma months, it's that if they have any other injury, whether it be an extremity fracture or a rib, just go ahead and pan scan everything else. Having one injury ++++++++++ odds that there are more
 

link2swim06

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FAST is done so frequently in residency for training purposes. To be able to read it correctly, you need to look at a ton of normals. If you just do it on patients that have the indication, you are going to be bad at it and your sensitivity will be poor.

I'm at a busy level 1 trauma center. It does change management on the hypotensive patients. Essentially confirms type of shock and helps determine if the surgeon is going to open the chest or belly first.

These are the people I could never imagine sending to CT scan. Like SBPs in the 50s and heart rates in the 150s already on the level 1 transfuser....
 
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WildcatS11

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Well, to be fair it takes a heck of a lot of force to fracture the spine of a young adult which can lead to other injuries that wouldn't necessarily declare themselves immediately. How long did you watch him before letting him go home?
The most commonly missed fracture? - the 2nd fracture.

With evidence of actual injury and a dangerous mechanism, you're taking a risk not looking for further injuries. Maybe not an enormous risk, but still some level of risk.

(And I understand you did an exam - I don't always trust an exam to be perfect, especially in these situations)
 
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UKEMdoc

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Main use I've found in FAST scanning is demonstrating to the gynaecologists that they can't mess around when I've got someone who looks like an ectopic with a HR of 130 and systolic of 100 - and significant intra-peritoneal fluid.

They are obligatory in trauma at any academic centre as without about 50 our registrars(residents) can't complete training. TFIC
 
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dpmd

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The most commonly missed fracture? - the 2nd fracture.

With evidence of actual injury and a dangerous mechanism, you're taking a risk not looking for further injuries. Maybe not an enormous risk, but still some level of risk.

(And I understand you did an exam - I don't always trust an exam to be perfect, especially in these situations)
I think you meant to quote the person i quoted because we are in agreement on the risk of missed injuries.
 

WildcatS11

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I think you meant to quote the person i quoted because we are in agreement on the risk of missed injuries.
You are right. Just continuing the discussion in agreement.
 

Arcan57

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You are right. Just continuing the discussion in agreement.
The question becomes, are we missing things that matter? In general, not usually. In specific, sometimes. Is lighting up some poor bastard's chest with stable vitals and an isolated rib fx on X-Ray with an otherwise negative secondary exam going to show something else? Possibly, usually an insignificant pulm contusion or a 2% PTX. Will you admit them feeling good that you caught the additional injuries? Probably. Did you help the patient? Probably not. Does it matter because you trained in a place or work in a place where any missed injury was paraded in M&M as an example of how EM docs are mouth breathing losers with the attention to detail of a coked up squirrel?
 

GeneralVeers

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BTW I didn't miss anything, and the eventual pan-scan was negative. I admitted the patient for the T-10 fracture, so there was no chance he was going home and would have a missed injury.
 
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dpmd

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BTW I didn't miss anything, and the eventual pan-scan was negative. I admitted the patient for the T-10 fracture, so there was no chance he was going home and would have a missed injury.
While I would have ordered the scan if you consulted me for the patient I wouldn't have made a complaint about you not ordering it in that situation then. It would be different if it was someone who went home though.
 

WildcatS11

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The question becomes, are we missing things that matter? In general, not usually. In specific, sometimes. Is lighting up some poor bastard's chest with stable vitals and an isolated rib fx on X-Ray with an otherwise negative secondary exam going to show something else? Possibly, usually an insignificant pulm contusion or a 2% PTX. Will you admit them feeling good that you caught the additional injuries? Probably. Did you help the patient? Probably not. Does it matter because you trained in a place or work in a place where any missed injury was paraded in M&M as an example of how EM docs are mouth breathing losers with the attention to detail of a coked up squirrel?
I feel like the whole argument that "the missed injury wasn't significant" is a bit soft.

For example, sure maybe there was a small Pulm contusion or tiny splenic lac. Maybe there would be no downstream consequences. But this doesn't really pass the "grandma test." I.e. What would you have preferred for your grandma or mother or whatever. I know that if my mother got in an MVC and had a splenic lac however small I would want her observed in the hospital. I realize that statistically one could argue against cost utilization. But let's be honest, especially in a young healthy person, a new traumatic injury is nearly the only thing that's going to kill them or cause morbidity, so why be cavalier about it?
 
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Arcan57

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I feel like the whole argument that "the missed injury wasn't significant" is a bit soft.

For example, sure maybe there was a small Pulm contusion or tiny splenic lac. Maybe there would be no downstream consequences. But this doesn't really pass the "grandma test." I.e. What would you have preferred for your grandma or mother or whatever. I know that if my mother got in an MVC and had a splenic lac however small I would want her observed in the hospital. I realize that statistically one could argue against cost utilization. But let's be honest, especially in a young healthy person, a new traumatic injury is nearly the only thing that's going to kill them or cause morbidity, so why be cavalier about it?
I don't completely disagree with you. The problem becomes that an admission has downstream effects that can be inconvenient (filing bankruptcy due to medical bills and delayed return to work) or dangerous (nosocomial infections, medication admin errors). You can definitely make the argument that those aren't your problems and you're only responsible for the patient's health at the time you are seeing them. There's also a small but real phenomenon of delayed complications (slow intercostal bleeds, delayed splenic rupture) which being hospitalized won't prevent. It's also possible that having multiple relatives die prematurely from hospital acquired conditions colors my view somewhat.

In a well-appearing young pt with an evaluable exam (no alcohol, no drugs, no concussions, no neuropathy, normal affect) I don't pan scan even with a bad mechanism. I don't think that's cavalier but I guess I can understand people that do.
 
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Dr.McNinja

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I feel like the whole argument that "the missed injury wasn't significant" is a bit soft.

For example, sure maybe there was a small Pulm contusion or tiny splenic lac. Maybe there would be no downstream consequences. But this doesn't really pass the "grandma test." I.e. What would you have preferred for your grandma or mother or whatever. I know that if my mother got in an MVC and had a splenic lac however small I would want her observed in the hospital. I realize that statistically one could argue against cost utilization. But let's be honest, especially in a young healthy person, a new traumatic injury is nearly the only thing that's going to kill them or cause morbidity, so why be cavalier about it?
Because the ones that die don't do it from subtle injuries.
 

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For the record, this doesn't happen in the real world. They still want the CT. Every time. And they'll tell you its so they "know where to look". As in, spleen vs liver vs something else.
Drives me up the wall.
Not where I work. Someone with a positive FAST and BP of 90 was taken to the OR a few shifts ago. CT happened after repair of their liver laceration. Didn't even get a head CT prior to going to the OR (despite GCS of 12).
 
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shookwell

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Not where I work. Someone with a positive FAST and BP of 90 was taken to the OR a few shifts ago. CT happened after repair of their liver laceration. Didn't even get a head CT prior to going to the OR (despite GCS of 12).
Where I work patients go to the OR if they have a positive FAST and borderline vitals.

If they are stable I still make the residents do a FAST so that they get to see a lot of negative ones. It's important to make sure the residents understand that it's not really indicated and only educational, one of the places I did locums the surgery residents were told they have to FAST everyone, which is fine, except no one really taught them when a FAST is actually indicated. They would get upset if I discharged minor trauma before they did a FAST. When I am working without residents FAST is only helpful every once in a while, the last one I did that changed my management that I can remember was over a year ago.
 

DrDrummer

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Respectfully, that's not what the author of that blog post is suggesting.

From his post you linked:

"The implication when reviewing this literature is that well appearing, evaluable patients presenting to the Emergency Department may be harboring clinically occult, life threatening injuries undetectable by a standard physical exam. And yet this interpretation is based off methodologically flawed retrospective analyses and prospective data sets in which the physical exam was all but neglected. More importantly this ignores the multitude of clinical decision instruments, derived and validated from high quality prospective data, demonstrating that imaging can be avoided using simple components from a history and physical exam."

The author followed it later with this post: http://emcrit.org/emnerd/case-anatomic-injury-part-ii/ which does an excellent job summarizing a recent study, the REACT-2 trial, which was a very well-done prospective study of > 1,000 trauma patients, which I think most people would say is the best data out there suggesting that pan scans as routine practice irrespective of physical exam findings / vital signs / patient complaints is not supported by data. Check it out. Rory Spiegel is a great writer and summarizes this stuff really well, and acknowledges the critiques that some people have of the study as well.

I say all this as a PGY-2, and definitely think it's a nuanced and tricky issue. I understand that it is easier to send everyone with a concerning mechanism to the doughnut of truth and identify issues, and am sure that it does save lives in some patients that might be well-appearing until suddenly they're not. I also understand that our collaborative relationship with surgery, who will definitively manage many of these patients and take responsibility for them means their opinions are important. But I think those patients are rare -- most of the patients in whom this will identify a life-threatening injury will declare themselves in other ways, and routinely pan-irradiating every healthy young person that comes in with the label of "trauma" attached to them seems like it will lead to more harm than benefit. I'm sure my perspective will change as a function of experience and responsibility though, so I try to remain open-minded about this and appreciate all the perspectives here from the attendings and our surgical colleagues that have weighed in.

Any of you ever do shared decision making about CT with trauma patients? One of our faculty is working on this right now, I think it has potential in this population of well-appearing, awake, alert, sober patients -- ever give them a choice?
 

TimesNewRoman

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Any of you ever do shared decision making about CT with trauma patients? One of our faculty is working on this right now, I think it has potential in this population of well-appearing, awake, alert, sober patients -- ever give them a choice?
No. I don't think a trauma patient is the right patient for shared decision making. With chest pain or appendicitis, you have a concrete problem that the patient can understand. With trauma, you have all sorts of possibilities beyond the basics that patients can understand. It's to hard to explain to them the negative predictive value of an abdominal exam, the baesyen (sp) statistics associated with the age, mechanism, vital signs, exam, etc.
 

WilcoWorld

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No. I don't think a trauma patient is the right patient for shared decision making. With chest pain or appendicitis, you have a concrete problem that the patient can understand. With trauma, you have all sorts of possibilities beyond the basics that patients can understand. It's to hard to explain to them the negative predictive value of an abdominal exam, the baesyen (sp) statistics associated with the age, mechanism, vital signs, exam, etc.
Plus, you're dealing with a patient population that is disproportionately represented at the Darwin Awards year after year.
 

gman33

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SDM in trauma depends on the type of trauma.
Little kid that fell down. Probably doesn't need CT head in most cases, but need parents on board.

old, hit head on Plavix, I just tell them what we are doing.
 
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Aesculapius

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Depends a lot on the reliability of the patient. Patient reliable and cooperative, even if the mechanism is somewhat concerning (like a rollover)? Not necessarily going to get pan-scanned if they have no findings on exam, no complaints, vitals normal. But they have to be pretty pristine. Elderly, intoxicated (even if no obvious injuries), hysterical? I just put them in the scanner and wait for the negative results, and don't feel bad about it.
 

shoal007

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last saturday had 6 drunk head traumas come in with small lacs, small hematomas and confusion. nursing gave me **** for CTing everyone but 1 had a significant SAH. Im unsurr if I would have been able to identify the correct patient clinically.The culture in community is to move these patients and not let them rot in our ED. so dont really have a choice. everything but kid with minor head trauma, i do the MDM.

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emergentmd

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last saturday had 6 drunk head traumas come in with small lacs, small hematomas and confusion. nursing gave me **** for CTing everyone but 1 had a significant SAH. Im unsurr if I would have been able to identify the correct patient clinically.The culture in community is to move these patients and not let them rot in our ED. so dont really have a choice. everything but kid with minor head trauma, i do the MDM.

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Drunks, Old, on Coumadin or the like, poor historian patients, high mechanism........ I will scan 99.9% of the time unless the pt refuses. Your pretest probability is not great and these pts tend to be terrible at follow up.

And Nurses should NEVER give you Crap for your decision making. I know they do, but you need to put them in their place early or deal with the constant crap.
 
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exsanguination

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I know they do, but you need to put them in their place early or deal with the constant crap.
What do you mean by this? How do you go about doing this? I am asking out of curiosity because I have similar interactions with the nursing and other ancillary staff, but pissing off a nurse is like pissing off your wife. Be ready for a world of hurt for the rest of the shift, and the next few as well! Lord forbid if you have a nursing union on top of that!
 

GeneralVeers

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If they question my orders, I find a little education usually helps. Nurses like to feel like they are part of the treatment team. If they know why they are doing test X or giving test Y, then they are generally going to be more helpful. I have found that "putting a nurse in their place" rarely has positive outcomes for the physician.
 
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Psai

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If they question my orders, I find a little education usually helps. Nurses like to feel like they are part of the treatment team. If they know why they are doing test X or giving test Y, then they are generally going to be more helpful. I have found that "putting a nurse in their place" rarely has positive outcomes for the physician.
It depends on the nurse. I've explained things explicitly to a nurse once and they continued to ignore my orders. Then they come by again later wondering why the patient's back pain is not better. I'm like I already explained it to you leave me alone