On trauma

Standard

One of my friends, who is also a paramedic among his other pursuits, asked me what EMS could do to take better care of trauma. He went on to cite a few skills that readily help, like splinting, hemorrhage control, and driving to a surgeon.

                Unfortunately, driving to a surgeon in the year 2014 is not the obvious answer anymore. The idea of trauma must be handled by a surgeon is historic only to the limited age of the trauma surgeon specialty. (1960’s-80’s) prior to that it was primarily the providence of both general surgeons and internists or as they called themselves, doctors. In fact prior to the acquisition of surgeons by medicine, the call was for “a doctor in the house” not “a surgeon in the house.”

                So how did this focus on surgery come to pass? Well, for starters surgeons cause trauma every day. Logically they should be expert about it. Unfortunately what is logical and what is practical are often opposed. The focus of the physiological effects of trauma are often lost in the act of qualifying patients for surgery, which includes determining if the pathology will be worse than the surgical operation. From the practical point it is not seen as a risk/benefit analysis, it is seen as a how bad is the pathology point of view.

                Another interesting point of that is the focus on inflammation and effects of trauma on the body. I mention inflammation specifically because not only does it have historical relevance to trauma, but it is also the focus of much of modern trauma research. When you open many surgical textbooks (I have read a couple) inflammation and particularly sepsis occupy a prominent role. In fact in one surgical textbook, sepsis is listed as a surgical disease! (Probably because historically, surgeons caused a lot of sepsis.) However, when you read in anesthesia and critical care texts, not only is the information on inflammation and sepsis often more detailed. (I can actually tell whether it was a surgeon or an anesthesiologist who wrote the chapter just by skimming it, because of the focus and detail from the respective specialist.)

                Because the days of exploratory laparotomies for every trauma patient are over and the obvious fact, often touted in countries where orthopedics are the lead in trauma care, most trauma is ortho in nature. (Bone and soft tissue) More so, the whole purpose of trauma care anywhere is to return victims to as normal as possible, and ortho does this far more and with far more intensity than any other surgical specialty.

                Modern trauma care can easily and usefully be divided into blunt and penetrating injuries. There is an interesting dichotomy to this I think. Minor and moderate blunt injuries have the best outcomes and severe blunt injury is almost futile to care for, where as minor and moderate penetrating injuries hardly require a surgeon, but severe ones are most amiable to surgical intervention and positive outcome from surgery. Simply, you probably will not require a surgeon for trauma, but if you do, only a surgeon will help.

                Another factor which is starting to remove the need for a surgeon in trauma is medical advancement. It used to be that things such as liver lacerations, splenic lacerations, and even pelvic fractures required open surgical hemorrhage control. While that is still true in some cases, low grade liver and splenic lacs can now be managed in the ICU without surgery, and these injuries including some vascular pelvic injuries can be managed by endovascular techniques, which is usually the realm of interventional radiology in many places and partially vascular surgery in some others.

                All of this has led to the question, who should ultimately manage trauma. Perhaps the most vocal proponent is emergency medicine. Certainly they are trained and have important skills to manage all forms of trauma. One of their most proud surgical skills is the emergent thoracotomy. However, while it certainly seems like a very effective skill, the opportunities to use it are limited to the most high volume centers. Many community EDs around the world I have seen are not even equipped to do it. But one of my early surgical mentors once pointed out during an ATLS class, “Once you open the chest, are you going to close it too?” While not an issue in the ACS level 1 academic trauma center, certainly it is an issue in the smaller emergency departments, which may not even have onsite surgical capability. Even if you do close it, how/where will this patient be managed “post op”?

                While certainly there is a place for this skill, other skills relating to life threatening trauma which might be used more often are absent, for example bilateral craniotomy for blunt head injury with increased ICP. A few years ago I took an informal poll on Facebook of physicians I knew who would even be willing to perform such a procedure. The only ones who voted in favor were surgeons. Almost all of the emergency physicians voted they would not perform such a skill, and only 2 opined they would be willing to use a “burr hole” which is less invasive and according to the studies I have read, not nearly as effective. I will also point out that I learned in my neurosurgery experience, that opening a skull is the most basic of all neuro operations, and usually done by first year neurosurg residents.

                As far as surgical skills go, most of them are actually pretty easy. No different from most psychomotor skills performed by paramedics. Certainly I think they are more exciting and it seems easy to be impressed by them. The real skill of a surgeon is deciding who would benefit from such interventions, and taking care of the patient before and after surgery and through rehab. (Which most have given up doing despite it still being a core part of surgical education.)

                So understanding all of this, the question remains what does the surgeon bring to trauma that others don’t? The role for ortho is obvious, they fix bones and other soft tissue related to motion in order to return to the pt to maximum function. But rarely are they emergently required. Vascular surgery has a role in severe penetrating trauma, and it is perhaps one of the few remaining “whole body” operators left in modern medicine, operating on vessels wherever they are found. General surgery can certainly be valuable in the remote or austere environment, but those opportunities are rare. Not to mention most of the injuries will be vascular in nature or relatively minor. In my experience in austere medicine, most injuries were ortho or minor and required only simple skills and aggressive “post surgical” treatment. (surgery in many cases was simple suturing, abscess drainage from infected wounds which were initially managed by non-physician providers, re-margining of disheased wounds, managing work/sports related injuries, and the occasional dislocation/fracture reduction and splinting before evacuating them to ortho) hardly the stuff of surgical legend. I will just give myself points and mention I was required to manage a complicated birth which thankfully was manageable with an episiotomy, because I was hoping to any higher power who might have influence that I was not going to be required to perform a field c-section with the limited equipment we had on site. But the fact is that lady would have been better served by an OB/Gyn, who are by definition, surgeons.

                EMS providers do not exist in some alternative world in trauma. Most of the injuries they see are isolated, often minor or moderate, and more rarely severe. There are some exceptions to this like those working in inner-cities, but even then, they see only a fraction of the patients the local trauma center does.

                This leads all providers to the “Oh my God! Oh no!” syndrome when they do see something that looks like surgical trauma. Most often it is not as exciting as they may anticipate. It is all about perspective. So let me offer some. When I teach all levels of providers from first responders to physicians, I show them a really great photo taken of a self-inflicted shotgun wound. (Taken by somebody that was not me, whose name I don’t know) The person is conscious and looks “fucked up”. I profess if the first thing that goes through your mind is “that guy is fucked up” you are most likely right. You don’t need to be a doctor to figure that one out. But when you have been around these patients for a long time, the definition of “fucked up” changes considerably. Most patients fall into the category of “yea, that looks worse than it is,” because not only have you seen it before, but your management is rather logical and routine, with commonly positive outcomes. Gunshots, stabbings, power tool accidents, and a host of others fall into this category. (I was actually formally written up and reprimanded at one of my EMS employers for “not sounding panicked enough when calling the hospital”, I did my paramedic clinical time and later came to work in one of the busiest trauma centers in the US, by the time I even finished paramedic school, trauma was not as exciting as it seemed in the past)

                One of the pitfalls of the inexperienced is estimated blood loss. Even people who spend a majority of time in the OR are notoriously poor estimators of blood loss. Even the best clinical techniques I have heard and use myself overestimate by a considerable margin. Even more problematic is using the commonly referred to ACS estimates of percentage blood loss for determining severity and they make no reference to individual patient response for preexisting disease, extremis of age, or any other obviously important factor. There is also considerable variance in the opinion on what “a lot of blood” is. For example, OB/Gyns during routine c-section estimate 300-400ml blood loss as “massive.” Ortho during knee replacements have a similar estimate after using power tools on the patient. As a proponent of vascular/cardio surgery though, I can tell you that is basically chump change. During aortic aneurysm repair, losing 1200ml of blood in a few minutes is not uncommon. Even a bypass or rupture of a femoral aneurysm may produce upwards of 800ml of loss. But with expert management by both anesthesia and surgery, many of these patients make a good recovery. This has direct implications on trauma care. First it demonstrates the need for early and aggressive treatments. Flavored water simply isn’t going to work when somebody loses >2000ml of blood. It is not even attempted. Another thing that is done is measuring inter-operative hemoglobin, hematocrit, and lactate levels to determine how individual patients are responding. One of my current mentors in surgery often likes to tease me about my interest in both surgery and intensive medicine by saying “Mike, you don’t need all those fancy machines and labs, if the drain is empty, the urine bag full, and the patient can tell you they are in pain, then the patient is stable.” While certainly true, it doesn’t tell you when they are unstable, or how much, which is really what determines treatment. (Yes, I am sure this professor of surgery is aware of that too, but it doesn’t stop him from teasing me.)

                One of the coolest pieces of equipment I get to play with is the bedside ABG machine. In about 2 minutes from putting in the sample, I get a host of useful information. The machine even self-calibrates and runs controls, who could ask for more? The reason this host of information is required is because no single indicator of shock is reliable. The goal then becomes to use a few to “triangulate” a reasonable estimate and act/adjust accordingly. I have no idea why EMS doesn’t use these machines. I can think of no other reason but cost. But the initial expense might save hundreds of thousands in the long run from over triage and unnecessary transport to “higher levels” of care, especially useful for providers without a lot of experience.

                    I speak a lot about hemorrhage (Haemorrhage for the British types, which is actually “hay-mor-hage” according to the rules, I am always fascinated by the random places Brits add an “A” and then don’t pronounce it) because it is the number one preventable cause of death in penetrating trauma. Some studies estimate as high as 40% of all preventable death. Direct pressure can control most bleeding, again studies and estimated as high as 90%. Even in vascular surgery, during procedures like carotid endarterectomies (where the carotid artery is purposefully and completely surgically transected), as well as all forms of open bypass, and aneurysm repair, direct pressure is the preferred method of bleeding control. I will also point out all vascular surgery patients are heparinized; which means direct pressure works to control major artery bleeding on heparinized patients every day and most often by without any adjunct. The second go to method is a form of chitin gauze in addition to direct pressure to locally counter the effects of the heparin. On minor vessels, including arteries, simple ligation and electro-cautery handles all of the work, but mostly for operative efficiency, not necessity. I recently opined EDs should have electro-cautery, this came from an experience where I was teaching a medical student the presentation and skills to identify and close hemorrhaging arteries in a trauma patient, and realized the device would have made minutes worth of work and materials only seconds with much less.

                The real key to hemorrhage control is access. In order to apply direct pressure you have to, well, be able to touch the place that needs pressure. While I like to think you have to be really bad ass to use a knife to stop bleeding, the truth is it is as simple as finding a leaky pipe in your house. You don’t use all kinds of chemicals and devices to find and stop a leaky pipe. You simply dig it up, destroying as little as possible on the way, and either replace or patch it. Again like many surgical skills, it is more of a matter of learning and practicing. The real trick is deciding when you need to vs. something like a tourniquet. (which is also used in surgery)

                A popular EMS mantra is “you should never stick anything inside a wound”. I am just going to call BS on this dogma. I stick things in wounds all day long; tools, gauze, fingers, sutures, synthetic plastic, sometimes metal and even a fair amount of water. The idea EMS cannot do something like pack a wound, is just self-limiting nonsense. But it makes a lot of money for medical gizmo manufacturers. Probably cheaper and easier just to teach medics how to effectively do it. Imagine a whole device industry that revolves around a totally unfounded self-limitation!

                Splinting is another “pre-hospital” technique of much renown. But it is highly underutilized. Not only for potential bone and soft tissue injury, it also can help control bleeding, wound healing, and pain control.

                Pain control is another monster in pre-hospital trauma. One of the limiting factors I am most often reminded of is “hemodynamic stability.” First it is almost laughable because blood pressure is a poor indicator of end tissue perfusion. let’s face it, BP is the measure of blood leaving the heart, not coming back, and the clinical sign of altered mental status will precede any significant drop in BP. Narrowing pulse pressure makes a quick and dirty estimate, but again, the problem must be profound to detect it. However, in any operation, whether general or regional anesthesia is used, some form of water is also used simultaneously to make up for vascular expansion and the drop in perfusion pressure from it, in this case not to deal with hemorrhage, but in container volume expansion. The goal of anesthesia is simple. Patient feels no pain, patient does not react to pain, and patient doesn’t remember pain. It is not “patient finds the pain level reasonable enough to tough out.”  Look at the management of severely burned patients. Even in the pre-hospital setting, RSI may be necessary simply to manage pain. What about local/regional anesthesia pre-hospital? Lidocaine is great on small wounds, digital blocks, and in fact any broken skin. Strangely enough most “sunburn” ointment is 0.5% lidocaine and it works great on not only sunburns but minor cuts and blisters.

                Speaking of burns, most burns, which are also trauma, do not require a burn center. Some people even get partial thickness (formerly called 2nd degree) sunburns and manage without a doctor or hospital at all. Silverdine cream (locally argosulfan) is a wonderful tool. (Also please recall not to include 1st degree burns as part of the overall estimate.)

                Ibuprofin is a wonderful tool for managing minor traumatic pain, both short and long term, especially in conjunction with something else. It even reduces the amount of other pain medication required. That whole bradykinin  pain threshold pathway… Even a single dose of steroid can have considerable effect on musculoskeletal pain. Those are often tools found in EMS, simply under-utilized.

                Perhaps the most important thing that can be done for trauma in the pre-hospital setting is not to send every patient to the highest level of care. Better would be the most appropriate level of care. It is often closer and cheaper, with no worse results. Airmed people especially hate this thinking. After all, they don’t often bring much in the way of actual treatment modalities to a scene. They even advertise speed. But the fact is once you close an open circuit rather than try to “resuscitate” and open circuit, then the amount of time you have increases greatly, by hours or days. You can even use a spineboard to indirectly apply pressure and control hemorrhage. (seen it many times)

                The best advice I could offer to EMS in terms of trauma care is simply, calm down. Look at what you are actually dealing with. A bleeding artery? Stop it from bleeding. A burn? Stop it from burning. Splint deformities, you don’t really need to know if there is a fracture to help. In fact, splinting soft tissue helps too! A freaked out patient in pain? Stop them from freaking out and being in pain. Try to use your tools to maximum effect, rather than trying to invent and have a tool for everything. Don’t worry about what “might happen”, plan for it. Get ahead of the pathology. Clean and explore the wound. Make seemingly complex problems simple tasks. For example an open fracture. That is usually not a dramatic bone sticking out, but a small wound with a retracted bone. Stop the bleeding, splint the site, relive pain, inspire calm, and drive to ortho. You don’t need a $20k helo ride. Mission accomplished.

                What really makes an expert in trauma is not their medical specialty, but the mindset and confidence in the way they handle it.                

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s