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IS it time to review the systematic approach we take for the early management of trauma?
The early management of severe trauma (EMST) protocol in Australia was adapted from the US Acute Management of Severe Trauma (ATLS). The American College of Surgeons developed ATLS in the 1970s in response to a need for a systematic approach to the early care of patients “suffering major, life-threatening injury”.
EMST focuses on the threat to life first, and guides the provider through a logical sequence of assessment and treatment.
However, this logical system seems to be used increasingly for every patient with trauma, morphing into a robot-like repetition of tests that bypass clinical logic.
My doubts about the way EMST is used were brought into sharp focus while I was recently working in the emergency department (ED). When I arrived in the ED, I found a school-age child lying on a trolley, neck in a rigid collar, looking scared.
He had fallen from his bicycle, hitting his face on concrete, and had been stunned for a few seconds but remembered the event. He had vomited shortly after.
Our hospital — which is not a trauma referral centre — recently started a team call system for surgical emergencies, including trauma. By the time I arrived, the primary and secondary surveys for this child had been completed and he had a cannula in the cubital fossa.
He was fully awake and said his neck was not sore, so I took off the collar, to his relief. His face was sore and grazed, and he had lost a front tooth. Luckily, Dad had brought the tooth (a permanent one) and we had it in a jar of milk.
At that point, the senior surgical registrar proposed doing a cerebral computed tomography (CT) scan on the basis that the child had hit his head and vomited. He also wanted a focused abdominal ultrasound.
As the boy had lost a tooth and had swallowed blood, the vomit was not such a worrying sign. He was fully awake and had hit his face but not his head. I felt his belly, which was not tender and had no external signs of injury.
I decided to spare the child the radiation of a brain CT for no good indication, preferring to observe him in the ED.
It was then that I remembered the tooth — an upper incisor dislodged with its root. We rinsed out the socket and our ED registrar re-implanted it, saving the child the need for a future cap.
We observed him further, contacted the paediatric dentist at the local children’s hospital, and later transferred him for a review of the tooth and assessment for any imaging that might be necessary around the face.
We saved him a CT scan, as well as a lost tooth, and the hospital unnecessary expense.
And this is when I reflected on how the EMST protocol is administered. At what stage did EMST become a series of unnecessary tests for the less severely injured?
With growing concern about overtreatment and overdiagnosis, a rational application of EMST principles can save patients from some unnecessary testing.
This child did not need us to save his life. But we saved his smile.
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.
Posted 25 February 2013
Another example yesterday – man with sternal fracture from seatbelt in MVA (anterior cortex only)booked for CT scan, cardiology review, cardiac monitoring, Troponins. He had normal heart rate and blood pressure, and only needed good pain relief so he would breathe up. Evidence on so-called “mycoardial contusion” has been out for 20 years, but people still wanting to do stuff that is out-of-date and not supported. Still occurring at consultant level, not just trainees. I even got the response “I know the evidence, but we’ll do it anyway.” (sigh)
My point is about the application of major trauma guidelines – not the guidelines themselves. Where was the senior supervision in the ED? I was it – and I circumvented the tests suggested by the surgical members of the Surgical Emergency Team. There was no senior surgical supervision present that day. Perhaps that was a contributing factor.
I’m not sure any Guidelines recommend unnecessary tests, nor what Guideline would recommend CT in the case described. Where was the senior supervision in the emergency department while the initial work up was being done ?
Well said Sue. The lifetime risk of a child developing a radiation induced cancer after a CT head and face is quite high so if the investigation is not needed, why do it? Rigorous observation is the key (after thorough examination) and we should not forget it!
Caroline Acton
Maxillofacial Surgeon
Well said Sue. ATLS guidelines were developed originally to assist the infrequent trauma care provider in a resource poor setting such as a rural hospital, not experienced clinicians in urban Emergency Departments. Over-reliance on imaging can lead to errors too, for example CT scan of the abdomen will detect solid organ injury but may miss a bowel perforation early on. The trend away from clinical assessment of the patient and blanket ordering of investigations for particular presentations is not only costly but is harmful to patients. All professional opinions have an inherent uncertainty. We can’t completely exclude every unlikely pathology and we need to enter into a conversation with our patients – they are actually more risk tolerant than we are. We are selling out as a profession if we let fear of litigation make us do things we know are dangerous and stupid.
Excellent stuff Sue. For “guidelines” to work they need to be shaped into unit “protocols”. These have limited application and are constructed solely by the clinicians at unit level and should be no more than a consensus agreement in the common sense application of arbitrary decisions.
Lebistourie makes a good point. The germs of good judgement are nurtured by the time honoured practice of “graded responsibility” where the assessments and plans of junior staff are tested by a senior before implementation. This diminishes progressively with increasing hands on experience. Sadly, experience is severely discounted in this era of obsession with credentials and blind adherence to guidelines. In my experience junior staff need a lot of support when learning that because a thing can be done it must be done.
Many older practitioners well remember the time before CAT and MRI scans and had to rely on their clinical acumen to make a diagnosis and order limited tests then available to confirm a diagnosis.
Today, over investigation is driven by the fear of litigation for areas of omission and or commission and again we only have the ambulance chasing lawyers to blame for this problem!
Policy and protocols will render medical practitioners irrelevant and the patient incidental. The other casualty is good medical common sense. Well put Sue.
Sue. I agree in part, guidelines are just that, to guide the wise and blind adherence emasculates the fools (apologies to WS).
Indeed p$ of the 9th ATLS manual has IN RED
(these) principles GUIDE the assessment and management and management of injjured patients.
JUDGEMENT is required to determine which procedures are necessary because NOT ALL patients require all of these procedures. (my capitals)
How to teach ‘judgement” – this is the role after the basics have been learned of people like you and I as senior clinicians, if done initially it will lead to slackness and missed problems, creating poor outcomes
I work within an emergency department as well. It seems to me that the ability to clinically assess the patient without undertaking a full range of pathology tests and irradiating the patient on ‘spec’ is fast disappearing. If a test or diagnostic procedure is questioned I’m told that its “defensive medicine”.
I love the comment from Geoffrey Kellerman that a new class of patient has been created: “The symptomless patient with an investigational anomaly”. He makes the point that a careful clinical assessment guides the judicious choice of investigations.
It would be an interesting research project to ascertain whether the combination of a good clinical history and physical exam coupled with a parsimonious use of investigations makes any difference to patient outcomes.
Well said Sue. We see this over investigate/over treat approach all the time – and not just trauma. The adrenaline of the automatic “team call” system brings a host of extra people into a situation where there is peer group pressure to order tests and do procedures to justify the call in the first place! Too many Chiefs, too many Indians and a scared patient caught in the cross fire. So a plea for a greater role of common sense in the ED rather than blind adherence to policy/protocol driven medical practice.