In the last post, I described the first crucial step in the contemporary management of penetrating neck trauma, control of obvious external hemorrhage. Let’s move on to the nuts and bolts of figuring out what needs to be done about the injury. Now, it’s time to triage your patient based on clinical signs that predict the presence or absence of a significant injury. In the old days, the neck was conceptualized as three different zones that dictated the diagnostic and management algorithm. We are now moving toward considering the neck as a single unit. The next decision point is to determine the ..read more

In my previous post, I described the early days of penetrating neck injury management and introduced a paper suggesting that this concept should be revised. Today, I will summarize a paper by Siletz and Inaba that is currently in press and outlines what the contemporary way of treating these injuries should be. Step 1. If present, rapidly control external hemorrhage and airway compromise. As always, bleeding should be controlled by direct pressure or packing. Direct pressure does not look like this: The goal is to create a zone of pressure higher than the systolic BP perfectly in the are ..read more

“When the facts change, I change my mind. What do you do, sir?” This is a famous quote from John Maynard Keynes. (Or is it? There is some debate over its authenticity, but you get the idea it tries to convey.) Our knowledge base continually changes, so we must be willing to change our minds (and practices) based on new, reliable information. The management of penetrating neck injury is one of those facets in trauma care that has undergone slow but steady progress over the past 40 years of my career. In the old days, we quickly identified the zone of injury and proceeded to the operating room ..read more

The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons: It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery It reduces the need to place the entire trauma center on divert due to surgeon issues However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one ..read more

Extraperitoneal rectal injury repair has evolved considerably over the past 40 years. Way back when, this injury automatically triggered exploration, diverting colostomy with washout of the distal colon, and presacral drain insertion (remember those?). We eventually backed off on the presacral drains (pun intended), which didn’t make a lot of sense anyway. And we gave up on dissecting down deep into the pelvis to approach the injury. This only served to contaminate an otherwise pristine peritoneal cavity. Ditto for the distal rectal washout. So we have been performing a diverting colostomy as ..read more

IVC filter insertion has been one of the available tools for preventing pulmonary embolism for decades—or so we thought. Its popularity has swung back and forth over the years and has been in the waning stage for quite some time now. This pendulum-like motion offers an opportunity to study effectiveness when coupled with some of the large datasets that are now available to us. IVC filters have been used in two ways: prophylactically in patients at high risk for pulmonary embolism (PE) who cannot be anticoagulated for some reason and therapeutically once a patient has already suffered one. Over ..read more

Generative artificial intelligence (AI) is the newest shiny toy. The best-known example, ChatGPT, burst onto the scene in November 2022 and caught most of us off guard. The earliest versions were interesting and showed great promise for a variety of applications. The easiest way to think about this technology is to compare it to the auto-complete feature in your search engine. When you start to type a query, the search engine will show a list of commonly entered queries that begin the same way. Generative AI does the same thing, just on a vastly expanded level. It looks at the question the use ..read more

In the last two posts, I discussed the size of your trauma bay and how to measure it. This can obviously be helpful if you are updating or building new resuscitation rooms. But what about all the stuff that goes into it? Where is the best place to put it? If you are in the enviable position of being able to stock a brand-new room, here are some tips. Figure out what you really need in the trauma bay. You don’t have to put everything and the kitchen stove in there. It’s fine to have less commonly used equipment somewhere else, but it must be close! You don’t want someone to have to walk 50 ..read more

In my last post, I detailed some standard info on trauma bay size. Today, I’ll describe what I found when I brought in my trusty tape measure a few years ago to check out the old trauma bays at Regions Hospital. I came up with several helpful measurements to help gauge the relative utility of the rooms. Here are the indices that I came up with: TBTA: Trauma Bay Total Area. This is the total square footage (meterage?) measured wall to wall. TBWA: Trauma Bay Working Area. This is the area that excludes equipment carts next to a wall, and areas under countertops that extend away from t ..read more

Medicine, in general, and trauma care, specifically, require frequent communication. These communications may be between two providers to maintain continuity of care or between providers and patients to explain it. Unfortunately, the Joint Commission has identified breakdowns in the process as a root cause of preventable events and a significant factor in preventable death. To address this problem, many centers have sought to standardize this process, which may include some of the principles in my previous post. However, until now, there have been no evidence-based recommendations for this pra ..read more