Big Trauma: Before the CT

before the CT

 

Efforts to standardize the approach to trauma have led to an algorithmic, thoughtless approach to trauma that over-utilizes CT in well patients and delays CT in ill patients. In critically injured blunt trauma patients, CT is a fantastically useful test and should be prioritized as the critical diagnostic step to be taken as quickly as feasible.

Classic teaching is that unstable patients should be stabilized prior to CT, but this is an outdated, dangerous paradigm; optimal care in severe trauma rapidly implements key resuscitative maneuvers so that resuscitation can continue simultaneously with CT. I have witnessed many cases where persistently hypotensive patients were observed in the trauma bay because “the patient might need to go direct to the OR,” but direct to the OR means direct to the OR; observation of an unstable trauma patient prior to elucidation of the injuries is usually the wrong strategy. Know exactly what the initial resuscitative priorities are in trauma so that as soon as they’re done, the patient can be taken to their next destination (CT, OR, IR). The following are carried out in parallel with universal first steps of resuscitation and the primary survey.

1. Staunch external bleeding. This can be accomplished with pinpoint pressure in almost all cases, occasionally a proximal tourniquet is required.

2. Resuscitative vascular access. Short, wide peripheral lines or a sheath introducer in a central vein is an immediate priority. Know the flow rates of commonly used catheters.

3. Blood. Do not delay initiation of your massive transfusion protocol in the unstable trauma patient when ongoing internal bleeding is likely. These patients should also receive tranexamic acid or other procoagulants/reversal agents if applicable.

4. Intubate. Nearly all critically injured trauma patients should be intubated expeditiously. Do a quick neuro exam first if possible.

5. FAST. Point of care ultrasound in trauma was devised for critically injured patients, but in most trauma centers is now done on everyone, slowly and methodically, as if we’re evaluating the gall bladder in an abdominal pain patient. Slow and methodical is fine when the patient is fine, but in the unstable trauma patient, ask the junior resident to step aside so that an experienced sonographer can answer several crucial questions in 30 seconds: First, does the patient have a pericardial effusion or an underfilled heart; second, is there a pneumothorax. third, is there free fluid in the abdomen or thorax.

6. Wrap pelvis. In blunt trauma, if the patient is demonstrating exsanguinating hemorrhage, don’t push on the pelvis, don’t wait for an xray, wrap the pelvis straightaway. This will have the additional beneficial effect of discouraging anyone from doing a rectal exam.

7. Chest tubes. Ultrasound can generally tell you which hemithorax requires a chest tube or finger thoracostomy but if you’re not sure and are managing an unstable trauma patient with evidence of thoracic injury, do not hesitate to place two chest tubes. The sicker the patient with chest trauma, the more likely you should place two chest tubes.

8. If the patient has head trauma and evidence of increased ICP, start hyperosmolar therapy.

9. Non-exsanguinating extremity injuries generally deserve a damn good ignoring during the resuscitation of a sick trauma patient, but while the brain and thorax are being tended to, if you have an extra set of hands it’s reasonable to bring a cold limb out to length. Do not delay life-saving maneuvers (which include CT) for a foot or hand which will be of no use to your patient if they don’t survive.

10. Plain films. ATLS has us doing an xray of the chest and pelvis on everyone. These are good tests but CT is a much better test, and in the patient clearly requiring whole body CT, plain films serve mainly to delay CT. The chest xray tells you whether to place chest tubes, which you can determine by ultrasound or just do empirically, and the chest xray tells you if the endotracheal tube is in the right place, which you can determine by physical exam (or ultrasound)–in a well saturated patient, the exact location of the tip of the ETT can wait for CT. The pelvis xray tells you whether you should wrap the pelvis, which should be done empirically when history and physical suggest it. In the dying patient being considered for therapeutic angiography instead of the operating room, if the ultrasound shows no culprit and chest tube output is low, it’s the pelvis. If your interventional radiologist won’t take the patient until an AP pelvis is done, do an AP pelvis.

Once the patient is intubated, resuscitative vascular access is achieved, and blood products are being transfused through a warming rapid infuser, resuscitation can be continued unabated in CT. In a critically injured poly-trauma patient, once these initial resuscitation maneuvers are in place, the options are CT, OR or an OR alternative. Continuing resuscitation in the trauma bay when it could be continued in CT amounts to observation, which is the wrong move in most cases. It is sometimes hard to know who can make it through CT and who needs the OR immediately–it’s a complex decision and you will sometimes be wrong, but in the dying trauma patient, if you choose to stay and play in the trauma bay you will usually be wrong. Commence resuscitation and, as a team, make a decision: CT, OR, or OR alternative. CT on the way to OR can be an excellent plan; the time it takes to get the patient to the OR and get everyone in position to operate is often all the time a radiologist needs to determine the most important life threats.

In summary: CT is an invaluable test in critically injured trauma patients and should be delayed only for a few key resuscitative maneuvers. Know what they are so you can get them done quickly, and so you can defer anything less likely to help the patient than CT.

 

thanks to CHAS, and KS for their review.

 

Rehearse on a sheet of newspaper: An acting coach critiques my SMACC keynote and tells me how I can do better

smaccdub-still

I thought there was nothing more excruciating than listening to myself in audiocasts, but then I was video-recorded at SMACCDub, and discovered that watching myself on video is even worse. So I sought the advice of a professional acting coach to improve my presenting mojo. I sent her the video of my presentation and she responded with these notes, which were so useful that I felt they were worth sharing.

 

Overall this is a strong talk, and you’re an engaging speaker. I enjoyed watching it. I have some thoughts on how you can fine-tune a few things, presented here in roughly chronological order.

One thing that stands out to me is that you tend to speak with your brows up, which makes your forehead get wrinkly and “hard.” This is a response to mild nervousness on your part which causes mild anxiety in your audience. If you can relax your forehead a bit, that would be great. To wean the habit, either get a gentle round of botox, or put a piece of scotch tape vertically on your forehead (from top of nose to hairline) while you rehearse the presentation. It will give you biofeedback when you wrinkle your brow. It will be distracting as hell, but it will help you gain awareness of the habit.

You tend to shift your weight a bit, which is probably not as distracting in person but on camera it’s too much movement; stillness would be better. This also comes from nerves–you don’t do it at all at 17:00, but you do it quite a bit around 2:20. When you’re comfortable, your body will reflect that state with increased stillness and more purposeful movements; you will shift your weight when you shift tone or subject, rather than doing it compulsively at unmotivated moments.  Again, biofeedback will help–my advice to young actors is to rehearse the talk while standing, wearing shoes, on a sheet of newspaper, so you can hear when your weight shifts. Wearing different shoes for your talks might help, too–the foam soles on those sneakers are going to make your entire stance more bouncy. Springy soles are good to help “lift” performers who tend to be overly rooted- but in your case that’s not a problem; harder soles would help ground you.

Weight shifting and tense forehead are very common reactions to the stress of presenting (other people nod their heads weirdly, or pace, or clear their throats, wring their hands, or any number of other tics). It will likely take months to wean these habits, don’t stress, you’re pretty good on these fronts already–working on them is just that last little bit of polish.

Around 12-13 mins in, when you talk about thrashing delirious people, you’ve really warmed into it–your delivery is smoother and more natural, and it feels like you’re speaking more in your own native turn of phrase to people you know, rather than giving a speech. That’s a sweet spot for you. You might be able to reverse-engineer this level of comfort; try to remember how you felt at that part of the presentation, dissect the reasons, and then recreate that feeling elsewhere in the presentation. Ideas for how to get that warmed up feeling at the top of the presentation:

– Give yourself a calm, private, focused atmosphere before starting the presentation. For instance, hide in a restroom far from the crowd, or duck into an empty room or stairwell, and rehearse the easiest, smoothest part of the script right before you start the presentation. This will help you tap into the emotional state of calm confidence. For rehearsal, try to create physical conditions that are as much like your performance as possible–stand up and look out at a large open space, focusing your gaze on at an imaginary audience, rather than looking down, looking into a corner, or letting your gaze turn inwards into memory land. Muscle memory works–harness it by rehearsing your stance and eyelines accurately (more on eyelines below).

Imagine a specific person in the audience and speak just to them. Pick a person who likes you, who’s interested in this subject and roughly as knowledgeable as the rest of the audience, and who you are NOT nervous about. Usually I find my nerves come from one or two specific imaginary or real people whom I catastrophize are peering at me from the audience and judging me. If I shift my imagined audience to just ONE person who I know is the perfect target for this talk, my tone will be right for the whole room. So never imagine “ladies and gentlemen,” instead imagine “talking to Greg” or whatever it takes. Who are you talking to? is question #1 for all acting, and public speaking is a form of acting. If the ideal target person is someone you’re close with and the talk is really important or intimidating, you could even go so far as to call them up and ask if you can deliver the talk to them privately as a form of intensive rehearsal.

– Alter the writing so the beginning of the presentation is more colloquial and less technical, which will help it sound more natural even if you feel a bit stressed.

– Add more jokes off the top. Jokes are great as you know, because they (a) engage the audience, (b) get the audience’s buy-in so they will cut you slack if you make errors or annoy them later, and (c) give you feedback – their laugh is authentic proof they like you and are listening, so you can relax.

As you’re rehearsing, pay attention to any parts of the presentation that consistently make you nervous or uncomfortable. Spend extra time on them and rewrite those parts if necessary–try not to have any sections that you dread, even a little bit. If you find a specific part of the talk is particularly hard to memorize, it’s a clue that the writing is weaker – perhaps you’ve inadvertently created non-sequiturs or used awkward phrasing. Rewrite those parts until they flow smoothly and are easy to memorize. This is a classic playwrights’ rule of thumb: good writing is easy to memorize.

Around 19:00 (ketamine) and again around 22:00 (CT/LP) you get a bit…intense. Intense for you is kind of a relative term, as you’re pretty mellow/consistent, but in these sections your pace accelerates and your tonal range flattens. Can you identify why? Is it because you’ve spoken about K so much that you’re going a bit by rote? Are you worried about time? Identify and address the cause so the tone through this segment can be a little calmer and more gracefully shaped–the ketamine part feels a bit like a bullet train. Maybe add some more jokes.

Are you reading a prompter? Your eyeline to the prompter is too low; can you raise the physical location of the prompter so your eyes are higher when reading it? Eyeline is important and often overlooked. I think you’re doing this pretty well already, but it bears mentioning: be sure your eye contact includes the whole audience. Eye contact is the net you use to draw the audience in–make sure to cast it out wide enough to get them all. Look at both sides right out to the edges, the front row, the back row, and right up to balcony.

I think it’s best to make true eye contact with specific people for about 3 seconds each, but if that freaks you out, you can cheat by looking at the spaces between their heads, and you can have a few default gaze targets that are along the back of the room, about a foot above the heads of the people in the back row. Angling your gaze upwards in this way helps your words to travel “up and out” to the audience, which draws them in–the amateur opposite is to look only at the front couple of rows, which creates a low, downwards eyeline, shoots your ideas into the floor, and shuts the back of the audience out. When you look slightly upwards, we can see you and connect with you better.

Answer this question out loud: What color is your bedspread? Your eyes probably darted up and to the right–but sort of blindly–as you remembered the answer. We tend to “look at nothing” for a second when we’re concentrating–for instance, carefully delivering a memorized speech–and those glazed, spaced-out eyes are a hindrance to connecting with the audience. So, as my favorite acting teacher used to holler at us mid-monologue, keep your gaze in the room. Work on being able to really look at people during your talk, rather than, say, hyperfocusing on the exit sign or sweeping your eyes around blindly. You want to actually see the people. You can practice at home by sticking little faces cut from magazines all over the wall (or use sticky notes with little faces drawn on), and actually look at each face for a few seconds as you speak. Or just look at actual objects in the room: the doorknob, the teapot, the rice cooker. Make sure your eyes are alive enough to really notice what you’re looking at, which will ensure that your eyes–like your feet, in an ideal world–are moving deliberately and with purpose.

The goal here is to keep your eyes, and by extension your awareness, alive, present in this room at this moment–to keep your eyes receiving, not just sending. A talk needs to send a message OUT, yes, but great speakers are great because they are simultaneously taking the audience IN. In most normal conversations, you probably achieve this state of simultaneous broadcast-and-reception without really trying; but when the pressure of the speech hits, we tend to shut down our receiving capabilities and become little automaton radios spitting pre-programmed words at the audience, so the listener may feel talked-at and tune out to some extent. During a speech, your ideal state of being is present and aware enough that if someone sneezed, you’d hear them and be able to say gesundheit without skipping a beat. Achieving this kind of awareness is super-advanced and takes a lot of time and practice- but it is truly the tipping point from good to great. As a bonus, it will also help ease your forehead tension and improve your posture–we tend to raise our brows and push our faces forward when we’re emphatically projecting, as though our ideas are a unicorn horn we’re stabbing at the audience–but when we are empathetically listening without judgement, our foreheads relax and our eyes soften, which lets the audience relax and allows them to hear you better.

Your little microphone cord loop at the back of your neck keeps distracting me. Look in a mirror and tuck that shit in.

Your tiny smiles when you’re about to make, or have just completed, a joke are delightful. It’s always fun to see someone enjoying themselves. This is why we love Saturday Night Live the most when the actors break character and giggle.

Try to wean out the phrase “you guys” (it comes up in the Q&A at 25:00), and replace with “you” or “you all”, etc.  “You guys” is gendered and lacks gravitas.

You also mentioned, and I agree, that in general your posture could use a bit of an adjustment. As a diagnostic, try this: stand up, open your arms wide into a T and then drop them back down. Your hands will probably end up in front of your thighs naturally (here is an exaggerated version). Now do it again, but this time slowly and deliberately lower your hands beside you, so your thumbs end up resting along the side-seams of your pants. As you lower your arms, try to initiate that final hand position long before you get there, and from your back rather than from your arms or chest–it should not feel like holding your arms back or puffing your chest out, it should feel more like you are pulling your shoulder blades gently together–that’s the posture you want.

You can do exercises to enhance this:  try things that open your arms wide against resistance, like bent dumbbell flies where you try to get hands higher than shoulders, to strengthen / tighten your trapezius and latissimus dorsi muscles, or do incline dumbbell flies with low weight, but relax your arms outwards and let gravity and the weights stretch your pecs and biceps. And try to place your head over your spine rather than out in front of your spine. You can also add in some pec stretches in doorways and against walls and on balls. Yoga would be a good challenge for you.

Improving your posture is a very long term thing- it would be hard and distracting and probably a bad idea to think about it during presentations so I suggest working on it during workouts and in your regular life- once you have it as a normal habit, it will happen automatically onstage. I spent YEARS fixing my posture in acting classes, singing classes, yoga, and even flute lessons, before it became second nature.

Strengths overall: You have strong content to offer, your voice is pleasant, well-articulated, comfortable and easy to listen to–you’re breathing well and using your vocal instrument in an easy, natural way. The talk is well-written, strikes a good balance between natural and formal, and it’s interesting, even to a non-clinician, which I think is saying a lot. It’s obviously a great talk, and you deliver it very well. Would love to see the next iteration of it.

Nicole Stamp is a toronto-based director, actor, and acting coach.

HelpCard and Opioid Misuse

HelpCardFrontHelpCard Back

 

 

 

 

 

HelpCard for printing with your printer

HelpCard for submitting to printing company

 

Pain & The Poppy: Emergency Care During An Addiction Epidemic

Slideset

Pain, Compassion, Addiction, Malingering

How to use opioids and how to not use opioids

Video + Slides (University of Toronto) (35 minutes + questions)

SMACC 2015 Audio (right click to download) (25 minutes)

SMACC 2015 Slideset

SMACC Podcast Page

EM Cases Discussion with Anton Helman and David Juurlink

 

opioid misuse flow

Opioid Discharge Instructions

You are being discharged with a prescription for an opioid pain medication. Opioids are powerful analgesics that can be very effective for pain but also have the potential to harm you.  You should only take opioid pain medications if you are still suffering with pain after you’ve optimized non-medication strategies (rest, position of comfort, ice, heat, etc) and non-opioid medications such as acetaminophen (Tylenol) and ibuprofen (Motrin).  Take opioid pain medications as prescribed; do not take more than prescribed or take the pills in a different way than prescribed.

Opioids often cause constipation, nausea, and itching. Opioids can also cause more dangerous problems such as feeling ill, excessive sleepiness, confusion, and falls. Older people and people with liver or kidney disease are more prone to these harms. You should not drive or perform dangerous work while using opioid pain medications.

If you take too much opioid pain medication, your breathing can slow or even stop, which can be fatal. This is how people die from an opioid overdose.

Opioids can cause acute physical dependence after only a few days, which means that if you take opioid pain medications for a few days and then stop, you might experience withdrawal symptoms such as muscle aches, pain, insomnia, feeling nauseated and ill, depressed, agitated, or anxious, and you might even crave more pills. If you take more opioid pills, these symptoms will be greatly relieved, however this is the beginning of a very dangerous cycle of dependence, which can lead to addiction. If it is possible that you are experiencing acute physical dependence, do not take more opioid pills and discuss the problem with your doctor.

Lastly, once this painful episode is over, dispose of any unused pills–you can take them back to the pharmacy or flush them down the toilet. Leftover opioid pills can be extremely dangerous to children, and are a major source of recreational use, especially among adolescents and young adults.

 

Opioid Misuse Phraseology

My job is to manage your pain at the same time that I manage the potential for some pain medications to harm you.

I know you are in pain and I want to improve your pain, but I believe that opioids are not only the wrong treatment for your pain, but that opioids are the cause of your pain. I think pain medications are harming you, and if you could stop taking them, your pain and your life would improve. Can I offer you resources that will help you stop taking pain medications?

Prescription pain medications, even when used as directed, can cause patients to become dependent, and I’m concerned that the pills we prescribed for you in the past, even though you were using them appropriately, you may now be dependent on them. We can help you break free of that dependence.

My most important job as an emergency doctor is to make sure there’s no emergency, so I would like to do some tests to make sure there’s nothing dangerous happening to you, and also I want to relieve your pain. But you will not receive any opioids while you are here, because I think opioids could be harmful to you.

Here is your prescription. I am not entirely comfortable giving you this prescription because I am concerned that you are being harmed by these pain killers. When you decide that you want to stop using these drugs, and I hope you do, we can help you. Here is a list of resources available to help you stop.

 

opioid-alternatives

 

Opioid Misuse Spectrum

 

John Oliver’s stunningly comprehensive, dead on accurate, often hilarious take: (20 minutes)

Your new angiocath will not relieve tension pneumothorax

Conventional teaching for treatment of confirmed or suspected tension pneumothorax in an unstable patient is immediate chest decompression with a large bore angiocatheter [1]. New generation angiocaths feature blood control technology, which allows a flash of blood to rise into the hub but will not transmit that blood out the end, which increases safety and decreases messes. Half of the departments I work in now stock blood control angiocaths; since this device is more expensive than its predecessors, you can expect all american hospitals will soon move to them.

Notice the blood control valve, which adds length to the hub compared to the same catheter without this feature.

BC Valve

 

2016-04-21 06.47.58

 

The blood control valve prevents blood from flowing out the hub but also prevents any other fluid from flowing through the catheter, including air. So stabbing your pneumothorax patient with this device will not decompress the chest.

Fortunately the valve opens permanently when it is pushed down by IV tubing, or by attaching a syringe.

valve is closed

attach syringe

now valve is opened

 

So place the angiocath as usual, then take a syringe, pull out the plunger, and twist it firmly onto the hub, until you hear your rush of air.

There are all sorts of problems with using any needle or angiocath to decompress pneumothorax, especially if you use the usual anterior approach, and you are better off in most cases performing a finger thoracostomy or quickly placing a chest tube. But if you do use an angiocath, be mindful of blood control technology, because if you place a catheter thinking you’ve relieved tension but you haven’t, now you’ve made a real mess.

BC angiocath in package

 

[1] See chapter ten of the sixth edition of Roberts and Hedges.

[2] I’ve pictured the Becton Dickinson device but many angiocath manufacturers offer the same feature under a variety of names.

Avoid Alcohol Withdrawal Admissions

 

NAAW

 

Alcoholic patients are predisposed to many dangerous conditions and present an array of management challenges for emergency providers, however at many centers, some of these patients present with uncomplicated alcohol intoxication and end up admitted for alcohol withdrawal. This serves no one’s interests because alcohol withdrawal is a condition that generally does not benefit from inpatient management; detoxification proceeds over several days and the patient is discharged, unfortunately often to resume drinking, no better off than before.

Though some alcoholics present in advanced withdrawal, requiring aggressive management and an ICU or step-down bed, many (most?) patients admitted for alcohol withdrawal present to the ED intoxicated and develop withdrawal in the department. Admitting this group is at best pointless and usually avoidable. There’s a lot of literature and discussion around treating alcohol withdrawal, but very little on how to prevent it, which perhaps is part of the problem.

The first step is to identify patients at risk for withdrawal. The most obvious risk factor is a history of alcohol withdrawal, especially prior admission for alcohol withdrawal; ideally these patients would be flagged at triage. Anyone who drinks every day is at risk, though. Most at-risk patients arrive to the ED drunk, but if a daily drinker presents not drunk (i.e. comes with some other concern) or is in early withdrawal, promptly dose librium and reassess.

Intoxicated alcoholics at risk for withdrawal should be reassessed frequently for alertness. Once the sobering alcoholic is alert he is at risk for withdrawal and the most pressing concern is whether he can be safely discharged. If yes, discharge.*  If he cannot be discharged for whatever reason (requires sutures, psychiatry, social work, an xray, etc.), dose librium and reassess (and re-dose) every hour or two, until he can be discharged or needs to be admitted for some other reason.

Librium dosing. I see librium dosed at 25 or 50 mg, which works as part of a taper in mild withdrawal, but is often inadequate in the severe alcoholic whose last drink was 8 hours ago. You can succeed with small doses if you’re able to keep a very close eye and redose frequently as needed, but in most busy ED’s, you’re better off with a bigger dose, which will give you more time to circle back to reassess. For patients at risk to withdraw but without signs/symptoms, I use 100 mg. If early withdrawal has already developed, I write for 200 mg, yes that’s eight tabs, thank your nurse for making sure you meant it. 200 mg is outside the guidelines, but oral chlordiazepoxide is very safe; I have used this dose on hundreds of patients without running into trouble with respiratory depression or excessive somnolence.

Caveat 1: Many alcoholics suffer with a host of comorbid medical, psychiatric, and substance problems beyond alcohol dependence. If these problems can be even partially addressed in a sustainable way during an inpatient stay, that admission is of benefit, even if the patient goes right back to drinking. My impression is that severe alcoholism so completely dominates the patient’s function that their accompanying problems cannot be meaningfully addressed unless and until the patient stops drinking. I am aware of no way to move severe alcoholics to sobriety other than high-intensity case management; if your hospital can set this up during an inpatient stay, by all means, admit.

*Caveat 2: An at-risk inebriate who sobers in the ED and is discharged must of course be able to acquire alcohol to avoid withdrawal. Though alcoholics are astonishingly capable of accomplishing this regardless of circumstance, it may not be safe to discharge a brittle alcoholic at the cusp of withdrawal at 4am. Have an honest conversation with him, if he won’t be able to get booze for a few hours, dose librium and observe for a few hours.

 

help me help you

 

 

Thanks to Lewis Nelson and Anand Swaminathan for their insights.