gator_trauma_manual final ay 2009-10

Trauma and Emergency Surgery Resident Manual

Division of Acute Care Surgery

Department of Surgery University of Florida

First Edition, June 2009

Authors

Jason P. Wilson, MD Tad Kim, MD

Dean J. Yamaguchi, MD Constance W. Lee, MD

Lawrence Lottenberg, MD, FACS John H. Armstrong, MD, FACS

2 |G a t o r T r a u m a M a n u a l

Contributing Faculty

Larry C. Martin, MD, FACS

Darwin N. Ang, MD Scott B Armen, MD, FACS

Philip A. Efron, MD John I. Hollenbeck, MD, FACS David W. Mozingo, MD, FACS

Winston T. Richards, MD, FACS

Director, Trauma and Aeromedical Services

Michele K. Ziglar, RN, MSN


Table of Contents

Prologue 5 Trauma rotation objectives 6 Trauma gator guidelines 9 Trauma bay roles and responsibilities 14 Trauma junior guidelines 15

Trauma alerts Trauma consults Night junior AM ICU work rounds Weekends Unit intern/resident Clinic The List Trach/Peg List

Trauma intern guidelines 23 Trauma alerts Night intern AM work rounds Daytime priorities

Service-specific conferences 25 Epilogue 28 Appendices

I. Rotation objectives by year-level 29 o PGY-1 o PGY-2 o PGY-3

II. Trauma Alert Criteria 33 III. Injury Grading Scales 34

o Liver o Spleen o Kidney o Pancreas o Diaphragm o Chest Wall o Lung

IV. Glasgow Coma Score Scale 37


V. Mangled Extremity Score 38 VI. Sample dictations 39

o Percutaneous tracheostomy o Percutaneous endoscopic gastrostomy

tube placement VII. Medical student guidelines 41 VIII. Tube thoracostomy (chest tube placement) 44 IX. Trach/PEG from start to finish 48 X. EAST practice guidelines 54 XI. Door Codes 55


Prologue

This manual represents a collective resident and faculty effort to enhance your preparedness for the trauma and emergency surgery rotation. This rotation is brisk and challenging. In many respects, it is a crucible that accelerates clinical and professional growth. The manual attempts to capture the multiple roles played by each resident year-level.

The rotation is designed around the six core ACGME competencies, and thus, it is fitting

that the manual begins with the objectives by competency, integrated across the PGY 1, 2, and 4 year-levels. Objectives are separated by year level in the Appendices. Review not only your level-specific objectives, but the other levels as well, so that you can see the context of the rotation in your surgical progression.

As you use the manual and experience the rotation, please share your thoughts about

revisions and additions that you would recommend.


TRE Service Clinical Rotation Objectives (By competency, across PGY-levels) Patient care

PGY-1: Demonstrate recognition of shock in the initial assessment of the acutely injured patient. PGY-2: Demonstrate appropriate primary survey and resuscitation of the acutely injured patient. PGY-4: Demonstrate appropriate initial evaluation and management of the acutely injured patient. PGY-1: Demonstrate appropriate pre- and post-operative management of acutely injured and acute surgery patients on the inpatient ward. PGY-2: Demonstrate appropriate evaluation and management skills in the care of service patients in the surgical intensive care unit and in acute surgical consultation. PGY-4: Demonstrate appropriate coordination of care, to include use of consultants and radiological imaging, in the management of trauma and acute surgery patients. PGY-1: Demonstrate effective, safe performance of techniques to stop hemorrhage, close simple lacerations, and place gastric and bladder catheters. PGY-2: Demonstrate effective, safe performance of procedures of resuscitation and of adjunctive critical care procedures (e.g., tracheostomy, percutaneous gastrostomy tube placement, and open abdomen dressing change). PGY-4: Demonstrate appropriate operative management of patients with acute abdominal disease and traumatic injuries of the neck, torso, and soft tissues, to include operating room preparation and damage control transition. Medical knowledge PGY-1: Articulate essential concepts for the initial assessment and management of acutely injured patients. PGY-2: Discuss management concepts for patients with traumatic brain, spinal, chest, and severe musculoskeletal injuries. PGY-4: Explain the specific evidence-based management of acute traumatic injuries by organ system. PGY-1: Describe the assessment, differential diagnosis, and initial resuscitation of patients with acute abdominal disease. PGY-2: Discuss the assessment and management of patients with gastrointestinal hemorrhage, abdominal catastrophe, and soft tissue infection. PGY-4: Review the specific assessment and operative management of patients with acute abdominal disease and gastrointestinal tract hemorrhage. PGY-1: Discuss the basic science that drives pre-operative and post-operative care, to include fluids and electrolytes, pain management, and anticipated complications. PGY-2: Describe the basic science that drives resuscitation and management of the critically injured and acute surgically ill, to include blood transfusions, nutrition, and prophylaxis. PGY-4: Review the basic science underlying the management of elderly, pregnant, and immunocompromised patients with acute traumatic injury and acute surgical disease. Practice-based learning and improvement

PGY-1: Describe successful management of post-operative problems for specific patients. PGY-2: Describe evidence regarding management and prevention of specific surgical complications.


PGY-4: Analyze trends and opportunities for process improvement by reviewing trauma and emergency surgery service statistics. PGY-1: Discuss injury and disease characteristics related to specific ward patients. PGY-2: Explain evidence-based management of specific critically injured and ill patients in the surgical intensive care unit. PGY-4: Review critical steps in the performance of operations in specific patients. PGY-1: Identify opportunities for care improvement in individual patient cases. PGY-2: Appraise performance of procedures in trauma resuscitation and the intensive care unit. PGY-4: Analyze operative execution and outcome in light of the operative plan for specific patients. Interpersonal and communication skills

PGY-1: Demonstrate clear and accurate written communication in ward progress notes and discharge summaries. PGY-2: Demonstrate clear and accurate written communication in intensive care unit progress notes and consultations. PGY-4: Demonstrate clear, concise, and accurate written communication in operative notes. PGY-1: Demonstrate clear and accurate verbal communication in the care of service ward patients. PGY-2: Demonstrate clear, concise, and accurate verbal communication in the care of service intensive care unit and consultation patients. PGY-4: Demonstrate clear, concise, accurate, and integrated verbal communication in the care of trauma and acute surgery patients. PGY-1: Demonstrates respectful and appropriate communication with patients, families, nurses, consultants, peers, and faculty. PGY-2: Demonstrates respectful and purposeful communication with patients, families, nurses, consultants, peers, faculty, and consulting services. PGY-4: Demonstrates respectful and purposeful communication with patients, families, nurses, consultants, peers, faculty, consulting services, and pre-hospital personnel. Professionalism

PGY-1: Demonstrates equanimity in interactions with patients, families, and all members of the health care team. PGY-2: Demonstrates equanimity in interactions with patients, families, and all members of the health care team. PGY-4: Demonstrates equanimity in interactions with patients, families, and all members of the health care team. PGY-1: Demonstrates appropriate appearance and affect for specific health care settings. PGY-2: Demonstrates appropriate appearance and affect for specific health care settings. PGY-4: Demonstrates appropriate appearance and affect for specific health care settings. PGY-1: Demonstrates effective time management (punctual, available, tasks completed on time). PGY-2: Demonstrates effective time management (punctual, available, tasks completed on time). PGY-4: Demonstrates effective team management. Systems-based practice PGY-1: Explain the role of pre-hospital care in supporting evaluation and management of acutely injured patients.


PGY-2: Explain the role of a triage system in appropriate disposition of acutely injured patients to the trauma center. PGY-4: Distinguish pitfalls in transitions from pre-hospital to hospital care and in inter-facility transfers for acutely injured and acute surgical patients. PGY-1: Describe resources available to facilitate the recovery of patients following definitive management of traumatic injury and acute surgical disease. PGY-2: Use appropriate outpatient management to promote recovery of patients from traumatic injury and emergent surgical disease. PGY-4: Summarize system challenges for patient recovery following traumatic injury and severe surgical illness. PGY-1: Discuss behaviors that lead to traumatic injury and acute surgical disease. PGY-2: Discuss interventions that can reduce the risk of traumatic injury and acute surgical disease. PGY-4: Differentiate programs that can reduce the incidence of trauma and acute surgical disease.


Trauma Gator Guidelines

1. The rule: 4 things you must know about every trauma patient (alert or pre-CT scan

consult) Systolic blood pressure GCS Hematocrit FAST

2. Everyone is bleeding until you prove they are not:

Vital signs O2 sat FAST Exam Chest x-ray Pelvis x-ray Hb/Hct pH/base deficit Lactic acid CT chest/abdomen/pelvis

3. Just do it: residents have the authority to upgrade to Trauma Alerts

BP less than 90 systolic GCS < 12 Penetrating injury, pelvic fracture, >1 long bone fracture (See Appendix II: Trauma Alert

Criteria) 4. EM attending is in charge of the trauma room until the trauma attending arrives, and then the

process is shared between the two. 5. The room must be silent when RSI intubation is being done; the only two people talking are

the intubating resident and the supervising attending.

6. Draw all blood via vacutainer tubes from the right femoral artery (not vein) after cutting or removing all clothing. Place the needle directly in the artery and hold pressure for 3 minutes after removing needle. A red top tube is immediately given to a nurse to run ISTAT: Hb, Hct, Na, K, Ca, Cr,

ABG, INR, PT, lactic acid. All other tubes are drawn, but in general only a BAL (EtOH) and Type and Screen is

sent to the lab; BMP, SMA22, amylase, and lipase are patient/disease-specific. 7. Hold pressure with left hand and place lubricant on the right index finger, lift one leg, and do

the rectal. Assess for blood, tone, prostate position, and bone fragments. 8. Place the Foley quickly and clamp the Foley until the FAST is completed.

9. X-rays: Obtain chest and pelvis only (no C-spine x-rays are done; CT is used to clear

cervical spine)

10. Mandatory radiographs on all falls from a height of 6 feet or higher, if mental status precludes adequate clinical exam Complete spine CT with reconstruction (cervical, thoracic, lumbar) Bilateral wrist x-rays Bilateral ankle (calcaneal) x-rays


11. Mandatory radiographs on all ejections (from a vehicle, motorcycle, ATV, bicycle, jet ski, boat) Complete spine CT with reconstruction (cervical, thoracic, lumbar)

12. For morbidly obese patients in whom adequate clinical exam may be more difficult,

consider extremity radiographs if clinical suspicion warrants, based on mechanism of injury. This can be done after the patient leaves the trauma room if the patient is in extremis.

13. FAST exam

Enter the patients name and number Turn the body marker on Depth should be around 17 for most adults Every exam is done in this order: subxiphoid RUQ LUQ pelvis RUQ. A copy of the FAST exam must be in every patients chart, no exceptions. If the printer is not working, save all images so they can be printed later.

14. Lines (if CVL and/or arterial line is indicated)

Place Arrow 9F soft triple lumen introducer in subclavian vein (if there is a chest tube on one side, use that side). Avoid putting introducers or CVL lines in the same side as penetrating chest trauma.

Place 5F 15 cm or 20 cm arterial line in right femoral artery (suture in place with the guide wire in the lumen, then remove guide wire and hook to monitor).

Place 9F Cordis stiff introducer for the femoral vein or saphenous vein cutdown. 15. Maintain sharps awareness at all times! If you perform the procedure, you are responsible

for disposing of the sharps. This is a major patient and health care team safety issue.

16. Obtain CT cystograms (dye instilled into the bladder during CT) on all patients with pelvic fractures and hematuria.

17. Be wary of open book pelvic fractures and apply pelvic binder to reduce pelvic volume.

Measure the diastasis on pelvic radiograph before and after placement of the pelvic binder 18. All trauma patients (consults or alerts) needing admission are admitted to the Trauma Service

for at least the first 24 hours.

19. Patients who should have both an introducer and an arterial line include: Patients in shock Patients with severe pelvic fractures or multiple extremity fractures

20. Be cautious with these injuries/characteristics:

Dislocated hip fractures needing reduction with multiple injuries Multiple extremity fractures requiring reduction and splinting/traction Elderly multiply injured

21. Call the ICU Fellow at 494-9189 ASAP when it is determined the patient needs ICU care. 22. After initial volume resuscitation, reassess the patient based on resuscitation endpoints:

mentation, exam, hemodynamics (BP, HR, CVP), urinary output, labs (Hgb/Hct, base deficit, lactate, pH, SvO2). Categorize the patient as responder, transient responder, and non-responder.

23. Seven sources of significant hidden hemorrhage Chest Abdomen Pelvic


Long-bone fractures Scalp laceration Oral/maxillofacial (swallowed) Blood left at the scene

24. If the patient remains unstable, the most likely source of hemorrhage remains the abdomen. Rule out abdominal source with repeat FAST or diagnostic peritoneal lavage (DPL) in select cases.

25. Remember to log-roll the patient prior to leaving the trauma bay; if you do not logroll, you miss half of the patients body surface!

26. Only call Ortho emergently from the trauma room for dislocations (hip, elbow, or knee) and mangled extremities; otherwise, wait until plain films and/or CT scans are completed.

27. Only call Neurosurgery emergently from the trauma room for focal neurologic signs, such as

blown pupil, paralysis, or GCS < 8; otherwise, wait until CT scans are completed.

28. All bleeding scalp lacerations should be sutured with running sutures or stapled by trauma or EM; do not call Plastics, OMFS or ENT emergently to the trauma room for these.

29. Scalp lacerations must be sutured with large (zero, 1-0 or 2-0) nylon or prolene running

suture or stapled, rapidly. All scalp wounds should be wrapped with Kerlex around the head and around the chin, and then ace- wrapped around the chin. The ace wrap should be removed in 30 minutes.

30. Leave the bottom of the fourth page of the H&P blank for the attending, and do not sign the

bottom of the fourth page. 31. No patients admitted to the Adult Trauma Service (16 or older) should go to the Pediatric ICU

under any circumstances. If this is going to happen, make the attending aware. 32. DVT prophylaxis

Lovenox prophylaxis is 30 mg sc b.i.d. Heparin prophylaxis is 5000 sc t.i.d. (CNShead and spinal cord injury).

33. IVC filters

Consult vascular surgery or Dr. Scott Armen for placement of IVC filters. ORMC guidelines for prophylactic IVC filter placement. Prophylactic IVC filters should

be placed in the following high-risk patients with contraindications to anticoagulation. (http://www.surgicalcriticalcare.net/Guidelines/IVC_filter.pdf)

o Age > 55 years with isolated long bone fractures o Severe head injury with coma o Spinal cord injury with paraplegia or quadriplegia o 2 long bone fractures with pelvic fracture o 4 long bone fractures o Penetrating pelvic venous injury

Without DVT: give prophylactic Lovenox until patient is fully ambulatory With DVT: give therapeutic Lovenox and then coumadin for six months

34. Antibiotics

Ventilator-associated pneumonia (VAP): 8 days IV o Start vancomycin and Cefepime. o Stop vancomycin after 3 days or when culture is not MRSA. o Stop cefepime if culture is MRSA and continue vancomycin.


o Consider double coverage for Acinetobacter or Pseudomonas, with extended course (10-14 days)

Blood culture positive sepsis: 14 days IV Catheter positive: remove the central line Hospital-acquired pneumonia (HAP): 10 days IV or PO Urinary tract infection (UTI): 7 days IV or PO Wound prophylaxis (administer within one hour and discontinue within 24 hours)

o Class I: Kefzol o Class II: Cefotan

Open fractures: Kefzol + gentamicin 35. Operating Room

When booking a trauma case in the OR, you must post the case by calling the Charge Nurse at 494-4890 and the Anesthesia Attending at 494-4990. You must state: I have a trauma case that needs to go to the trauma room and give the specifics of the case. If you do not tell the charge nurse the case needs to go to the trauma room, it may get put in a room with no equipment in it. Tell the OR if orthopedics, neurosurgery, or facial trauma is going to work with the trauma team. Give the OR the patients disposition: direct to OR immediately, CT scan first, or ICU first.

Prep the patient from the chin to the mid-thighs, down to the table laterally and with a groin towel. Prep right over groin lines.

All EKG leads must be on the back. Have the cell saver ready on all chest or abdominal cases; harvest the blood whether

or not there is a bowel injury. The individual trauma attending can decide whether to use the harvested blood.

Consider placement of a Sandoz nasojejunal tube on abdominal cases, based on anticipated need for nutritional support and patient stability. It is highly recommended to fully Kocherize the duodenum to aid in placement. Suture the tube to the center of the nose. Run D10W in the jejunal port at 10cc/hr immediately upon arrival in the ICU or PACU.

Obtain two radiographs of the abdomen to look for retained laparotomy pads or instruments on every trauma case (except damage control open abdomen), one from the nipples to the umbilicus and another from the umbilicus to the bottom of the pelvis. The entire peritoneal cavity must be covered.

Obtain chest radiographs on all thoracotomies or sternotomies (except damage control open chests) to look for retained laparotomy sponges or instruments.

For post-splenectomy patients who are non-ICU bound and stable, order vaccines to be administered on post-operative day 5 in the immediate postoperative orders. For post-splenectomy patients who are ICU bound, order vaccines to be administered on post-operative day 14 (or on transfer to the floor, whichever is sooner).

o Pneumococcal vaccine:

For adults and in fully immunized children 2 years of age, administer the 23-valent pneumococcal polysaccharide vaccine (PPV23)

For incompletely immunized children 2 to 5 years of age, and previously unimmunized children 5 to 9 years of age, administer the 7-valent conjugate pneumococcal vaccine (PCV7)

o Haemophilus B conjugate vaccine

Administer the Haemophilus influenza type B conjugate vaccine

o Meningococcal vaccine For patients 2 to 55 years of age, administer the meningococcal

conjugate vaccine (MCV-4) For patients 55 years of age, administer the meningococcal

polysaccharide vaccine (MPSV-4)


36. Respect the listkeep it updated. The list is an essential tool for patient safety and care

continuity.

37. You have not spoken to the TRAUMA ATTENDING until you have personally spoken with him/her either by cell, home, or land-line phone.

38. 80 hours/week means 80 hours/week.

39. Call your TRE attending with any questionsan attending is available to you, 24 hours/day,

365 days/year.


Trauma Bay Roles and Responsibilities

RRT

CC Tech

Sr. Resident

Jr.

Resident

EM Resident

Medical Student/

PA(H&P/Orders)

Nurse 2(Scribe)

Attending

Trauma & ED

Sr. Resident

PGY5/PGY4/PGY3

FAST

Introducer-Subclavian

A-line-Femoral Artery

EM Attending/EM ResidentAirway- edentulate, tongue, RSI

Breathing- end tidal CO2, ambu, NG/OG

Pupils, TMsSuturing scalp lac (no staples)

Nurse 1

Change field IVs to warm IVs, Second IV, Manual B/P

Vital signs including core temp., Warming measures

Attaches monitors: B/P, pulse oximetry,

EKG electrodes, End tidal CO2Monitors & reports physiologic parameters

Assists with procedures as appropriate

Prepares patient for transport

Obtains equipment, supplies, medications

X-RaysCXR, Pelvis

JR ResidentVacutainer

Femoral Artery

ABGs

Lactic Acid

Hgb/Hct

BMP/PT/PTT-

Elderly, CHI &

Anticoagulants

BA- all drivers

ETOH suspicion

Rectal Exam

Foley Catheter

Nurse 2 (Scribe)

Documentation on Trauma Flow Sheet

Ensures overall coordination of room

Completes lab slips, applies patient

bracelet, places phone calls for: orders,

diagnostics, admission

Radiology

Tech

RRTAirway adjuncts

Suctioning

End tidal CO2Ambu

FAST

Nurse 1

CC TechAttaches monitors:

B/P, pulse oximetry,

EKG electrodes, End

tidal CO2

Performs CPR

Assists with

procedure set-ups

Obtains equipment

and supplies

Charge Nurse

Assists with coordination

of patient care

i-STAT

11/09/07, 03/01/08


Trauma Junior (PGY-2) Guidelines

1. Trauma alerts

a. Preparation

i. Make sure the room is ready when you arrive. ii. Make sure that the ultrasound has the correct trauma patient and MR

number, paper and gel. iii. Make sure that the I-stat kit is ready for the intern. iv. Make sure printer paper is loaded in the ultrasound machine.

b. When the patient arrives, your role is to evaluate and manage the chest, abdomen,

and pelvis, yet in the context of the primary survey (ABCDE). A: Airway. C-spine immobilization. Ensure airway patency and assess need for

airway protection or ventilation. (ER resident at the head) B: Breathing and ventilation. Examine the neck and chest. Injuries that should be

identified in the primary survey are: tension pneumothorax, flail chest with pulmonary contusion, massive hemothorax, and open pneumothorax. C: Circulation with hemorrhage control. Assess hemodynamic status Identify and control obvious external bleeding. Establish IV access and/or central access if necessary, then begin fluid resuscitation. Examine the abdomen, pelvis, and perform the FAST exam (adjunct to primary survey) to identify potential sources of internal bleeding. D: Disability. Assess level of consciousness, GCS, pupils. E: Exposure/environment control. Undress patient and keep patient warm.

i. As the trauma junior, you will be evaluating the chest, abdomen, and pelvis. ii. Perform the FAST after the blood draw and before radiographs. iii. Make sure the lights are down and that you place the pictograph marker

appropriately.

c. After ABCDE is Resuscitation. Treat/manage/reverse immediately life-threatening injuries identified in the primary survey.

d. If the intern misses the groin stick after two attempts, then you should draw the blood as a way to teach the intern how to do the groin stick correctly and efficiently.

e. If central access is required, place a subclavian line (i.e. CVP monitoring, additional line necessary for resuscitation, or large bore peripheral lines cannot be placed). ** All surgery residents need to complete the CVL training module prior to placing a CVL **

i. Perform in complete sterile fashion with full universal precautions and sterile

field (e.g., big drape). This can be done even in high stress situations and has been shown to reduce the risk of catheter-related infections. In the trauma room, there is a kit that contains sterile gown, sterile sheet, Biopatch, and Tegaderm.

ii. Review the NEJM video on subclavian vein central line placement (www.nejm.org).

f. Adequate line/tube fixation is an essential part of every tube/line/drain procedure. The standard is three-point fixation. Tie the suture first to the skin, and then wrap the suture limbs around the tube/line/drain before applying the knot. Avoid the U-stitch, as this may cause underlying soft tissue ischemia.


g. You may perform or assist the intern with arterial line placement. Arterial lines are indicated in patients with need for close blood pressure monitoring (i.e. hemodynamic instability, vasoactive agents) or frequent blood gas or blood sampling requirement. The preferred site is the right femoral artery, and a 5 Fr, 15 cm long catheter is used. Arterial punctures are made at an acute angle, not at 90

o (not perpendicular), and are

not dilated. The sequence is stick, arterial flow, wire, catheter, stitch (before pulling out the wire), pull the wire out, connect to the transducer, confirm arterial tracing, dress, and tape the tubing to the patient. Verify that the transducer is zeroed. Often a repeat I-stat is sent to monitor resuscitation at this point.

h. CT imaging with contrast is preferred through a peripheral IV that has lower flow

rates relative to a central line. Peripheral IV access occasionally is difficult, and thus, central access may be required. Historically, the radiology techs have been reluctant to proceed with an intravenous contrast CT scan using a central line. However, the trauma service has arranged with radiology to permit this when there is not another viable IV. Peripheral IVs should not be placed in the foot.

i. If the patient has a history of allergic or anaphylactic/anaphylactoid reaction to contrast, try to avoid a contrasted CT scan. If contrasted CT scan evaluation is absolutely necessary, use low osmolarity (i.e. Visipaque) and minimum possible dose to complete the scan. Data have not clearly demonstrated benefit with pre-medication (with cortisteroids + antihistamine).

j. Remember that intravenous contrast is not benign, and our trauma population includes chronically ill and elderly patients with renal insufficiency. Obtain an I-stat creatinine level on patients with any history of renal insufficiency and those with age > 55. Administer Mucomyst, 1200 mg IV, in the trauma bay before CT scan, for patients with renal insufficiency or age > 55.

k. Patient disposition after CT scanning depends on findings. The intern should

accompany patients to the ward, and the junior and/or chief should accompany the patient to the SICU or OR. The junior or chief resident obtains the CT scan readings. During the day, this requires two visits, one with body-CT and the other with Neuro-CT (for head and neck). Make sure that you communicate up (chief, attending) and down (intern, physician extenders) the chain about the radiological readings so that situational awareness is maintained and appropriate consults are obtained.

2. Consults

a. Respond expeditiously: log in your time of consult, perform the consult (see and

evaluate the patient), report to your chief and/or attending, dictate the consult or admission H&P, write the orders, and complete the bed request.

b. With a trauma consult, the question to be answered is, Does the patient need to be admitted? More often than not, the answer is yes. Do not banter with the consulting emergency physician about the validity of the consult.

c. Every trauma consult should have the four key pieces of data (GCS, Hct, SBP,

FAST) and identified injuries (clinical and radiological). Make sure that ETOH level and urine drug screen results are recorded as well. Each of these items should be included on the patient list, and the ER should provide them when they call for a consult. Patient disposition must be part of the plan.

d. In your rapid assessment, determine if the patient is really a trauma alert disguised

as a consult. You have the ability to upgrade any trauma to a trauma alert. Be particularly cautious under these circumstances:


i. ER to ER transfer ii. Open book pelvic fracturethere can a large amount of initially subclinical

blood loss. Patients with open book pelvic fracture need to have an introducer, pelvic binder, and arterial line. Converting to a trauma alert brings resources that move care quickly; otherwise, you are recruiting help piecemeal with an active circulation issue, which places the patient at risk.

e. Hospital-to-hospital transferred trauma patients may come with outside films and

readings. We cannot rely on outside readings without films, and often, the outside CT scans have not been performed to trauma criteria. Thus, inadequate scans should be repeated. Outside torso CT scans may be reviewed (with dictation) by a radiologist on a case-by-case basis. Scans done within the Shands system (SUF, AGH, Lake Shore, Stark) will all have images and official dictations within the Shands computer system (remember to look up by name, not SUF medical record number, for non-SUF images) and are sufficient (but it is a good idea to review the films with the UF radiologists).

f. By definition, a consult is a communication between two physicians; thus, each consult should include an opening statement, Asked by Dr. X [consulting physician] to evaluate patient for Y [general purposeabdominal pain, traumatic injury, etc]. The top of every consult should state requesting attending, service (e.g., Green or Orange medicine or ER), and reason for consultation. Make sure that there is adequate space for the attendings to write a note on the consult. Attendings should be notified of any procedures to be performed, so that they can ensure appropriate supervision; these include bedside/ER incision and drainage, chest tube insertion, and central line placement.

g. Consult responsibilities may be shared with anesthesia and emergency medicine residents on the service. Although less than ideal, it is acceptable to have the night float intern see consults during times of overwhelming workload. That being said, no matter who sees the consult (attending, chief, intern), you are responsible for knowing all consult patients and you are responsible for having the data. On rounds in the morning, you may be the only initial continuity between night and day.

h. Hand-offs between care settings are particularly vulnerable points in patient care.

When you admit someone from the ER to the floor, call the night float intern for patients on the service lines and the trauma intern for TRE to give a report and review the pertinent issues. Same goes for transfers of ICU patients to 10-5 or IMC to 10-5.

i. Intraoperative consults require a rapid disposition. Be sure to notify your chief

resident and attending as soon as possible. Approach these consults by determining what the operating service wants from the consult; whether the problem is medical (intraoperative judgment), intellectual (experiential knowledge), technical (approaches), or social (turf awareness); and whether the preoperative diagnosis is still correct.

3. Night junior (and preparation for the morning)

a. A key principle to surviving the night is get everything done for the morning ASAP before the flood of consult/trauma alert patients arrives. Unlike life on other services, the night on TRE is simply a continuation of the day, and work should continue as if it were day time.

b. Work to get done includes: i. All check-boxes: Follow-up studies, post-op checks, pre-ops, and

procedures.


ii. Template notes: print out and start writing all of your template notes for the next morning. Blank templates are kept in the overhead shelf in ICU POD 3. Fill in date (for next day), time, HD#, POD# and the surgery, most recent DVT study, IVC Filter, antibiotics/other meds like DVT/GI prophylaxis, and cultures. You can even fill in the assessment and plan section if you already know (which you should). For billing and documentation purposes, it is important to list the relevant/current diagnoses in the assessment section; avoid making the A/P section just a plan.

iii. The list: Update the list with most recent cultures, pre-albumin, antibiotics with start/stop dates, and recent DVT study.

iv. Unit/IMC rounds: Round at least twice throughout the night, and write a short note entitled TRE late/night check to document patient issues (you should also use this time to simultaneously fill in your AM note templates). Perform a chart check to see what the day consultants recommended, including PT/OT and rehab.

c. Anticipated morning transfers: Write transfer orders for patients who you know or believe will be transferred. Fold them over so the nurses do not prematurely activate them

d. Anticipated next day OR: Verify pre-operative preparation/pre-op note and write in advance any post-op orders for patients going to the OR.

e. Daybreak: at 4:30AM, update room numbers and print a working list. Start filling in

the list and notes with labs, and otherwise update the list. Confirm the status of weekly DVT screening exams and order as appropriate.

f. Know where your students are at night. If they are not attached to you by the hip,

know where they are and get their pager numbers. Make sure a student scrubs on each and every case. Have them with you on ER work-ups and admissions so they learn what an acute abdomen looks like. These students will eventually be residents in the ER or on medicine and it is important that they know as much as possible so that when they call in the future they will be as educated as possible. It is tough to teach and be a trauma junior, but the more you do it, the easier and more natural it becomes. You can also tag-team trauma consult admissions with them (they do the H&P; you do the exam/orders).

4. AM ICU work rounds

a. Process:

i. The chief resident reads out the ventilator settings, vitals, ins/outs, and meds/antibiotics.

ii. The unit junior writes the note. iii. The day junior writes data on the list. iv. The night junior and medical student check all wounds, trach sites, G-Tube &

chest tube sites, and chest tube function (amount, leak), and then document findings under wounds in the note.

b. For every ventilated patient, document PaO2 and FiO2 (to calculate P:F ratio). Also document PEEP setting (changes in PEEP and FiO2 can alter the P:F ratio in lung-injured patients) in the note. Use a calculator and match with additional criteria to diagnose ARDS (p/f


d. Remember nutrition: Crucial for 5 days at full feeds, then Pivot 1.5.

e. Place transfer orders to facilitate patient flow through the hospital.

f. Review prophylaxis: i. Venous thromboembolic (Lovenox, subcutaneous heparin, sequential

compression devices, IVC filter) ii. Stress ulcer (on patients who will be NPO or are on the medication at home)

Ranitidine, 150 mg po bid Prevacid, 30mg po q day or bid

g. Upper GI bleeding

i. Prevacid, 30mg IV bid ii. Change to Prevacid, 10mg IV bolus + 6mg/hr gtt if UGI bleeding & Hct drop

h. Be sure to write PT/OT/rehab consults on Mondays and Fridays.

5. Weekends

a. Saturday is a challenging seam in the management of the trauma service because

the on-call resident (and sometimes attending) complement is cross-covering and not primarily assigned to the service.

b. You should round on the floor with the intern. One of the trauma chiefs does round until 9 AM, and then you are the senior resident who knows the service. It is best to complete rounds before the attending arrives in order to find and address any fires before learning about them with an attending. if you have the time, take ownership and be the acting trauma chief. Run the list with the intern before you depart on Saturday afternoon and at 6 PM on Sunday as is done during the week.

c. Communication is key: it is particularly vital in the world of shift work and 80-hour

work weeks. This means that there should be communication when you are off as well. On the weekends, the juniors should talk to each other. Phone calls should be made so that the other junior knows the plan. For example if the night person may be off from Friday morning to Sunday morning, the other junior should call the night junior to discuss the patients so that both know the plan.

6. Unit intern/resident

a. The unit intern or resident is a great resource. Having been the junior many times

without one, it is much nicer to have one. Know that you are responsible for what they do, so run the list several times. You and the unit resident should stay in frequent communication. There is a range of experience across the unit residentssome have never taken care of an inpatient outside of the OR or ER. It is a good idea to review their orders at first, e.g., fentanyl/propofol/versed drips written for the floor are less than ideal). Teach them to take out chest tubes, perform wound assessments, and change VAC dressings.

b. When you are overloaded with consults, have them see the consults. The ER residents in particular should help see consults and act as the junior resident on service. Teach them the head-to-toe work-up and write-up of H&P/orders for a trauma consult. Teach them the work-up of general surgery consults, especially acute abdomen.

c. At a minimum, the unit intern/resident should be focused on the unit and doing unit

things (f/u cultures, radiographs, tertiary surveys, antibiotics, nutritional parameters,


etc). Just make sure you know what they know because when check out comes at 6 PM or at sit down rounds, you are responsible for what they know, did, or didnt do.

7. Clinic

a. Clinic is on Tuesday mornings and scheduled from 9 AM to 11 AM. It realistically

goes until noon. It is not really that different from when done as an intern, but more is expected of you. As the junior, you will often be asked to see patients by yourself, with the students, and with the interns and ARNPs as necessary, all the while answering pages.

b. There are 22 booked patients and, theoretically, 8 slots for overbooking so that you have 30 patients booked per week. Especially during times when clinic is manned by just 3 people (junior, PA/ARNP, and medical student), the key to finishing before 11:30AM is non-stop efficiency and speed.

c. The patients who are following up after discharge, have NO general surgery/trauma issues, and present for either suture/staple removal, wound check, or just for non-operative trauma follow-up, should literally should have focused, brief visits. Medical students can help knock these out fast; just make sure they write a note that you can use for dictation. Get these done fast, so that you are ahead of the game when you face either a pre-op or a complex patient.

d. All pre-ops need to be seen by an attending before being booked. Booking a

patient involves a full H&P, consent for operation and blood products, OR scheduling sheet (includes check-boxes for pre-op labs, imaging, CXR), radiology form for special imaging (i.e. for barium/ostomy enema before ostomy takedowns), and updating the Trauma OR scheduling book (to be done by junior or chief, under the planned date with patient name, procedure, # of hours anticipated, and check boxes with what is done, like H&P/consent, and what is pending, like a barium enema). Pre-op efficiency is enhanced by filling out the consent (blood and operative) and H&P template before walking in the room and following this sequence: go into the room, do your H&P, get the consent, ask the patient for dates that will/wont work for OR, staff the patient with the attending, fill out the scheduling & imaging ordering sheet (if applicable), pencil the patient and operation in the Trauma OR schedule book, and book the case with the scheduler.

e. All H&Ps and clinic notes are dictated. In general, it is advisable to dictate the clinic

notes at the end of clinic. If you saw the patient with an attending, be sure to dictate that Dr. X saw and evaluated the patient.

f. Papers regarding insurance and disability are dispositioned through the physician

extenders.

g. If there is a trauma alert during clinic, it is up to the attending du jour and the chief to determine who goes to the alert and who keeps plowing through clinic. If you get a consult while in clinic, use your clinical judgment and the judgment of those in clinic with you (attending, chief) regarding whether it can wait until after clinic (trach/peg) or if it should be seen now (free air).

8. The List

a. The list is the essential tracking tool for patient care on the service. Each patient is

listed with an acute care surgery attending. If the first-call attending is not an acute care surgery attending, then list the backup attending. Along the same lines, when doing bed requests for Trauma Alerts, the admitting attending should always be an acute care surgery attending.


b. Under diagnosis, only put the actual diagnoses and be specific. For example, if the

patient has facial fractures, list what they are (there is a big difference between an orbital blow out fracture or a LeForte II fracture, and a non-displaced nasal septal fracture). The mechanism (i.e., MVC, fall, GSW, etc) goes in the text box.

c. In the text box, please write the age, mechanism of injury, and the critical four (GCS

field/ER, SBP, Hct, FAST). As applicable, include EtOH and urine drug screen results. Next, document the CTs ordered (h/cs/c/a/p as above if they got a pan scan) and key events (e.g, if the patient was intubated enroute, in the ER, or in SICU). After that, list pertinent plans by consult services, most recent negative DVT, most recent prealbumin, the date they had an IVC filter, and pertinent culture-antibiotic data.

d. Get into the habit of sitting down once a day and updating the list with chest x-rays

on the intubated patients, cultures, antibiotics, DVT study results, and prealbumins (on Monday). Remove outdated material.

e. The list is vital. It really cannot be emphasized enough.

9. Trach/PEG list

a. Tracheostomies and gastrostomies are not benign procedures; they deserve

continuity in follow-up so that emerging issues are found as early as possible and addressed. Further, our availability for these post-operative patients signals our commitment to referring services for future such referrals.

b. Make sure each patient that has a trach/peg or an OR-placed gastrostomy/jejunostomy is on the trach/PEG list and that it gets updated at least once a week. You should update patient location on the list (either use Navicare or electronic census). Be careful because HIS rounds report will indicate that patients remain in rooms long after they have died or been discharged, so it is best to check in patient demographics and then pull up cases/visits. The trach/PEG list is frequently full of patients who have either been discharged or died, which is poor form.

c. Check on these patients at least once a week. If there is no unit resident, then the night junior should perform the trach/PEG list rounds. If you do have a unit resident, have that person round on the trach/PEG patients twice a week. A short note should document the assessment of the trach/G-tube function, site, and security (intact suture fixation). Make sure that patients with G-tubes have an abdominal binder in place. Tracheostomy shields are sutured to the skin in four corners with 0-silk, and a tracheostomy tape is applied around the neck. Gastrostomy tube bolsters are sutured to the skin in four quadrants, and the tube is then sutured in a gentle loop to the anterior abdominal wall to prevent tension and unplanned removal, all with 0-silk sutures. This can be a good task, with direction, for medical students.

d. In general, patients stay on the main list for one night following their trach/PEG, and then are transferred to the trach/peg list the next morning. Sometimes, we pack the trach and the packing should be removed on POD#1 before transfer to the trach/PEG list.

e. PEGs are used immediately, prior rate for 24 hours, then increase to goal. The same applies for IR G-tubes (on our service). There is a protocol on the computer for


feeding/G-tube management; it includes erythromycin, unless otherwise contraindicated (prolonged QT), and an abdominal binder.

Trauma Intern (PGY-1) Guidelines

1. Trauma alerts

a. The intern is responsible for the femoral arterial stick, rectal exam, and Foley catheter

placement. Rule out a urethral injury (high-riding prostate on rectal exam or blood at urethral meatus) prior to placement of the Foley.

b. The intern makes sure that the bed request, CT scan request, H&P, and orders are donethe medical students are very helpful with these. The bed request goes to the bed request table across from the trauma bay, and the CT scan request goes to the ER front desk. Get this in early as radiology will not let you come down to the CT scanner without paperwork in the computer and faxed by the ER to them.

c. If the patient is stable and you are experienced and comfortable with the femoral stick, then it is acceptable to teach the medical students how to do this. The general rule in the trauma bay is that everyone gets two attempts with the groin stick and lines before someone else takes over. If you are struggling, look to the junior or chief for help. Remember that the femoral artery runs half way between the pubic bone and the anterior superior iliac spine and sometimes a blind stick is necessary to obtain blood. There should be no hesitation. Prep the groin with a Hibiclens swab, then feel the artery or stick where the artery runs. This should be done at a 90

o

angle. The arterial blood is sent for an arterial blood gas and other trauma labs. Hold pressure for three minutes with your left hand. With your right hand, do the rectal exam. Make sure you tell the patient what you are doing. Simply lift one leg and do the rectal exam.

d. Once the rectal is done and is normal, then you can place the Foley. A simple Foley should be placed in non-intubated patients. A temperature Foley should be placed in intubated patients. Only females should place female Foley catheterssometimes, this means a female nurse in the ED.

e. Once the patient is down in the scanner, the intern should add the patient to the list, starting with age, name, mechanism, +/- restrained, +/- ejected, LOC, GCS, FAST, Hct, SBP, EtOH/urine drug screen (if applicable or known), what CT scans and additional radiographs are being done, intended consults and whether or not they are aware/were called, and any preliminary readings (indicate as prelim).

f. While in the CT scanner, double check the medical students H&Pmake sure everything is filled in. Write admission orders (or confirm medical student orders). Include DVT prophylaxis, GI prophylaxis on patients who will be NPO, pain medications, stool softeners (for when taking PO), anti-nausea (Zofran) and anti-itching (Benadryl) medications unless there is a contra-indication. Do not write for Lovenox or GI prophylaxis on any patient who is admitted for observation and is expected to go home the next day.

g. Make every attempt to fill in the third page of the trauma history and physical exam with the reads from the scanner. Head and c-spine reads are preliminary until reviewed by a neuro-radiologist. Chest/abdomen/pelvis CTs are considered to be final when read by a resident radiologist.


2. Night intern

a. Similar principle as with the juniors: get all check-boxes done so that you are ready for anything that may come up.

b. Perform post-op checks, pre-op/consents, and any other check boxes from sign-out.

c. Write a pre-op note that lists the procedure, blood needs/ordered, and antibiotics. Patients admitted for ostomy take-down will need to have rectal pouch enemas, in addition to mechanical bowel prep.

d. Tee-up anticipated morning discharges. Fill out the discharge paperwork, home

instructions, and scripts, and then dictate the discharge summary. Anticipation helps to prevent the service from growing out of control.

e. Round on the floor patients and do chart checks to make verify PT/OT disposition

and any other late consult recommendations.

f. Write your floor template notes for the AM. Much of the note can be filled out (except for labs and vitals), to include date, time, HD#, POD#, surgery, antibiotics and other medications, DVT and GI prophylaxis, most recent DVT study, IVC filter, and brief assessment/plan (which you should know). 3

rd-year medical students on trauma call

do not fill out our service progress notes.

g. Write post-op orders (and fold them over) for patients going to the OR the next day

h. Once you have everything done, touch base with the junior and offer help. Make yourself available to the junior either to help with check-boxes or pre-ops, consults, or better yet, procedures like chest tubes. Start to learn the junior role for next year.

i. By 4:30AM, update room numbers, print out a long list, and fill in vital signs/labs for list and notes.

3. AM work rounds

a. The purpose of AM rounds is to set proper conditions for patient success and

attending rounds.

b. Verify patient status, do an exam, check incisions, change dressings, and write orders to begin normalizing patients who are close to discharge. Do not spend too long with any one patientyou should be able to complete floor rounds in an hour.

c. Both the night and day trauma interns round together, along with a trauma chief and

physician extender. However, if there are cases in the OR, then you might still need to round alone.

d. Think about disposition and removing IMC status on patients are they progress on

the care pathway. 4. Daytime priorities

a. First, dischargesideally, the night intern will have teed them up for AM discharge.

Get final reads, clear collars, complete tertiary surveyswhatever you need to do to get that patient out of the hospital. Med students can help with reads & tertiaries.


b. Call consultantswhether for new consults or to obtain follow-up/final recommendations. For all consults, you must know why the consult is being requestedwhat is the question to be answered. If you do not know, ask!

i. For all of the consult services (Orthopaedics, ENT, Neurosurgery, OMFS), the person you want to talk to is the resident or ARNP/PA on the service of the attending who staffed the initial consult (not person on the call pager).

ii. To track down the relevant resident, see who wrote the morning note. If you cannot read the signature, get the 6 digit doctor # from the note and give it to the clerk, who can look up their pager for you.

iii. Alternatively, check for a dictated consult or a note indicating the attending, and then call the on-call pager to ask who is the resident for Dr. X.

iv. Along similar lines, call the services home floor (50075 for Ortho, 50065 for Neuro) and ask the clerk or charge nurse who first call is for Dr. X.

v. Do not assign medical students to call consults this is inappropriate.

c. Be sure to write PT/OT and rehab consults as patients arrive on the ward. PT/OT orders must be renewed post-operatively.

d. Get your procedures done pulling chest tubes, drains, dressing/VAC changes.

e. Tee up any pre-ops for the next day: this includes consent for operation and blood, posting the case (usually done by junior or chief), pre-op note to verify appropriate work-up including labs, CXR/EKG, or further work-up if indicated, orders for NPO after midnight, IVF after midnight, T&S or T&C, labs/coags, and antibiotic on-call to OR. Use the pre-op note as a checkpoint to

i. Verify SCDs, DVT & GI prophylaxis. ii. Continue Atenolol, 50 or 100 mg po, or metoprolol, 5-10mg IV on call to OR.

Hold only if HR < 55 or SBP < 100.

Ideally, for outpatients, this should be started in clinic. iii. Hold any therapeutic Lovenox in AM iv. Set the insulin regimen for insulin-dependent DM patients.

For patients on intermediate or long-acting, give roughly half of usual AM dose, less (1/3) if surgery will make pt miss breakfast & lunch, more (2/3) if only missing breakfast.

For patients on multiple short-acting doses, give roughly 1/3 of their pre-meal dose.

v. Anticipate perioperative steroid needs (2-3 days) of patients on chronic steroids or hydrocortisone infusion for more than 2 weeks.

Pulse steroids, hydrocortisone, 100mg IV on call to OR, then 50mg IV q8h x 1 day, then 50mg IV q12h x 1 day, then 25mg IV q12h x 1 d.

4 mg hydrocortisone = 1 mg prednisone.

f. Do the stat dictation and discharge instructions for patients destined for rehab in the next day or so.


Service-Specific Conferences 1. Multidisciplinary conference

a. This conference occurs at 0730 on Monday and 0800 on Friday, excluding holidays, and is designed to bring every resource to bear for the acute care and recovery disposition of every service patient. It gets everyone playing off the same sheet of music, and brings accountability to care processes. Participants include the surgical team, nursing staff, PT, OT, social work, case management, rehabilitation, respiratory therapy, and dietary.

b. This is not a full ICU presentation. For new patients, present the story: age, mechanism, LOC, GCS, FAST, Hct, SBP, EtOH/UDS, relevant studies, all identified injuries (from most to least important), consult (neurosurgery, orthopaedics, facial trauma, PT/OT) recommendations, and plan. For patients who are well-known, say the name, age, mechanism, and major injuries/diagnoses, then move to current issues events overnight, overall neuro, respiratory, hemodynamic status, wounds, UOP/drain/NG output, relevant labs (Hct, WBC), tube feed status (TF at goal), consult recommendations and plans. Make sure you know individual service plans for the patients. Think about long term disposition for each patient.

c. On Mondays only, the night team stays and talks about patients admitted or operated during the previous 72 hours. Then the day person does the rest. The day person is responsible for presenting all of the patients on Friday. This is also a good time to make sure you know every services plan (part of the reason we round early on Monday) so you can decide if they belong on TRE or would be better served on another service (orthopaedics, neurosurgery, ENT). The idea is to help our patients move along the care pathway as expeditiously as possible. Focus on ensuring smooth transitions between care settings (e.g., ICU to ward, ward to home, ward to rehab, etc).

d. Ward patient discussion should include return of bowel function (e.g., for bowel surgeries) and activity level (e.g., pt transferred to chair or walked 100ft with PT and is ready for discharge).

e. Be prepared to run the list in the TRE conference room (M603, 6th

floor outside the trauma offices) on Tuesday (before clinic) and Thursday mornings (after service M&M). The unit resident should hold the pager while the PGY-2 is in conference on Tuesdays.

2. Trauma Quality Improvement Conference

a. This occurs on the third Tuesday of each month, from 7 AM to 8:45 AM.

b. It has two components, a trauma service statistical and case review, and an educational session.

c. All residents and students attend.

3. Acute Care Surgery Morbidity and Mortality Conference

a. This occurs every Thursday from 8 AM to 8:45 AM in M603.

b. Complications are identified prior to the conference, and a list is presented by the day

trauma chief resident. All residents and students attend.


c. The service participates in the Department of Surgery M&M conference on a six-

week cycle. Service statistics are reviewed, and a case is presented by one of the trauma chief residents.

4. TRE Chief: The Curriculum

a. This is a PGY-4 course with two components, a Tuesday morning, 7 AM7:30 AM,

oral review conference, and an electronic journal club with weekly assignments.

b. The texts are Top Knife and Copes Diagnosis of the Acute Abdomen.

5. Surgery 101, 201, and 401: The service supports full resident participation in these courses on Friday, Tuesday, and Thursday, respectively, from 7 AM to 8 AM. Clinical responsibilities are covered within the service during these times.


Epilogue Being on trauma is far from a perfect world. People in neighboring counties like to be involved in traumas all at the same time, so I know that Ive spent the whole night in the ER. I know all of this is demanding and hard to keep straight. Just do everything with the patient in mindthat is the most important thing.

Graduating Resident


Appendix I: Rotation Objectives by Year-Level

PGY-1 Objectives

Patient care PGY-1: Demonstrate recognition of shock in the initial assessment of the acutely injured patient. PGY-1: Demonstrate appropriate pre- and post-operative management of acutely injured and acute surgery patients on the inpatient ward. PGY-1: Demonstrate effective, safe performance of techniques to stop hemorrhage, close simple lacerations, and place gastric and bladder catheters. Medical knowledge PGY-1: Articulate essential concepts for the initial assessment and management of acutely injured patients. PGY-1: Describe the assessment, differential diagnosis, and initial resuscitation of patients with acute abdominal disease. PGY-1: Discuss the basic science that drives pre-operative and post-operative care, to include fluids and electrolytes, pain management, and anticipated complications. Practice-based learning and improvement PGY-1: Describe successful management of post-operative problems for specific patients. PGY-1: Discuss injury and disease characteristics related to specific ward patients. PGY-1: Identify opportunities for care improvement in individual patient cases. Interpersonal and communication skills PGY-1: Demonstrate clear and accurate written communication in ward progress notes and discharge summaries. PGY-1: Demonstrate clear and accurate verbal communication in the care of service ward patients. PGY-1: Demonstrates respectful and appropriate communication with patients, families, nurses, consultants, peers, and faculty. Professionalism PGY-1: Demonstrates equanimity in interactions with patients, families, and all members of the health care team. PGY-1: Demonstrates appropriate appearance and affect for specific health care settings. PGY-1: Demonstrates effective time management (punctual, available, tasks completed on time).


Systems-based practice PGY-1: Explain the role of pre-hospital care in supporting evaluation and management of acutely injured patients. PGY-1: Describe resources available to facilitate the recovery of patients following definitive management of traumatic injury and acute surgical disease. PGY-1: Discuss behaviors that lead to traumatic injury and acute surgical disease.


PGY-2 Objectives Patient care PGY-2: Demonstrate appropriate primary survey and resuscitation of the acutely injured patient. PGY-2: Demonstrate appropriate evaluation and management skills in the care of service patients in the surgical intensive care unit and in acute surgical consultation. PGY-2: Demonstrate effective, safe performance of procedures of resuscitation and of adjunctive critical care procedures (e.g., tracheostomy, percutaneous gastrostomy tube placement, and open abdomen dressing change). Medical knowledge PGY-2: Discuss management concepts for patients with traumatic brain, spinal, chest, and severe musculoskeletal injuries. PGY-2: Discuss the assessment and management of patients with gastrointestinal hemorrhage, abdominal catastrophe, and soft tissue infection. PGY-2: Describe the basic science that drives resuscitation and management of the critically injured and acute surgically ill, to include blood transfusions, nutrition, and prophylaxis. Practice-based learning and improvement PGY-2: Describe evidence regarding management and prevention of specific surgical complications. PGY-2: Explain evidence-based management of specific critically injured and ill patients in the surgical intensive care unit. PGY-2: Appraise performance of procedures in trauma resuscitation and the intensive care unit. Interpersonal and communication skills PGY-2: Demonstrate clear and accurate written communication in intensive care unit progress notes and consultations. PGY-2: Demonstrate clear, concise, and accurate verbal communication in the care of service intensive care unit and consultation patients. PGY-2: Demonstrates respectful and purposeful communication with patients, families, nurses, consultants, peers, faculty, and consulting services. Professionalism PGY-2: Demonstrates equanimity in interactions with patients, families, and all members of the health care team. PGY-2: Demonstrates appropriate appearance and affect for specific health care settings. PGY-2: Demonstrates effective time management (punctual, available, tasks completed on time).


Systems-based practice PGY-2: Explain the role of a triage system in appropriate disposition of acutely injured patients to the trauma center. PGY-2: Use appropriate outpatient management to promote recovery of patients from traumatic injury and emergent surgical disease. PGY-2: Discuss interventions that can reduce the risk of traumatic injury and acute surgical disease.


PGY-4 Objectives Patient care PGY-4: Demonstrate appropriate initial evaluation and management of the acutely injured patient. PGY-4: Demonstrate appropriate coordination of care, to include use of consultants and radiological imaging, in the management of trauma and acute surgery patients. PGY-4: Demonstrate appropriate operative management of patients with acute abdominal disease and traumatic injuries of the neck, torso, and soft tissues, to include operating room preparation and damage control transition. Medical knowledge PGY-4: Explain the specific evidence-based management of acute traumatic injuries by organ system. PGY-4: Review the specific assessment and operative management of patients with acute abdominal disease and gastrointestinal tract hemorrhage. PGY-4: Review the basic science underlying the management of elderly, pregnant, and immunocompromised patients with acute traumatic injury and acute surgical disease. Practice-based learning and improvement PGY-4: Analyze trends and opportunities for process improvement by reviewing trauma and emergency surgery service statistics. PGY-4: Review critical steps in the performance of operations in specific patients. PGY-4: Analyze operative execution and outcome in light of the operative plan for specific patients. Interpersonal and communication skills PGY-4: Demonstrate clear, concise, and accurate written communication in operative notes. PGY-4: Demonstrate clear, concise, accurate, and integrated verbal communication in the care of trauma and acute surgery patients. PGY-4: Demonstrates respectful and purposeful communication with patients, families, nurses, consultants, peers, faculty, consulting services, and pre-hospital personnel. Professionalism PGY-4: Demonstrates equanimity in interactions with patients, families, and all members of the health care team. PGY-4: Demonstrates appropriate appearance and affect for specific health care settings. PGY-4: Demonstrates effective team management.


Systems-based practice PGY-4: Distinguish pitfalls in transitions from pre-hospital to hospital care and in inter-facility transfers for acutely injured and acute surgical patients. PGY-4: Summarize system challenges for patient recovery following traumatic injury and severe surgical illness. PGY-4: Differentiate programs that can reduce the incidence of trauma and acute surgical disease.


Appendix II: Trauma Alert Criteria Adult Criteria (any one of the following)

Active airway assistance more than oxygen Lack of radial pulse with sustained heart rate greater than 120 or systolic blood pressure

less than 90 mmHg Best Motor Response of less than or equal to 4 (withdraws from pain) OR

o Paralysis OR o Suspected spinal cord injury OR o Loss of sensation

2nd or 3rd degree burns greater than or equal to 15% TBSA OR o Amputation proximal to wrist or ankle OR o Penetrating injuries to the head, neck, or torso (excluding superficial wounds

where the depth of the wound can be determined 2 or more long bone fracture sites (humerus, radius/ulna, femur, or tibia/fibula) Paramedic discretion Adult Criteria (any two of the following)

Respiratory rate greater than or equal to 30 Heart rate greater than or equal to 120 Best Motor Response of 5 (localizes pain) Major degloving injury OR

o Flap avulsion greater than 5 cm OR o Gunshot wound to the extremities

Single long bone fracture from MVC or fall greater than or equal to 10 feet Age greater than or equal to 55 Ejection from motor vehicle (excluding motorcycle, ATV, bicycle, or the open body of a

pick-up truck) OR o Steering wheel deformity


Appendix III: Organ Injury Scales Liver

Grade Injury Type Description

I Hematoma Subcapsular, 75% of hepatic lobe or >3 Couinauds segments within a single lobe

Vascular Juxtahepatic venous injuries (retrohepatic vena cava/central major hepatic veins

VI Vascular Hepatic Avulsion Advance one grade for multiple injuries up to grade III

Spleen


I Hematoma Subcapsular 5cm or expanding

Laceration >3 cm parenchymal depth or involving trabecular vessels

IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularizes the spleen

Advance one grade for multiple injuries up to grade III


Kidney Grade Injury Type Description

I Contusion Microscopic or gross hematuria, urologic studies normal

Hematoma Subcapsular, nonexpanding hematoma without parenchymal laceration

II Hematoma Nonexpanding perirenal hematoma confined to retroperitoneum

Laceration 1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation

IV Laceration Parenchymal laceration extending through the renal cortex, medulla, and collecting system

Vascular Main renal artery or vein injury with contained hemorrhage

V Laceration Completely shattered kidney

Vascular Avulsion of renal hilam, which devascularizes kidney

Advance by one grade for bilateral injuries up to grade III

Pancreas Grade Injury Type Description

I Hematoma Minor contusion without duct injury

Laceration Superficial laceration without duct injury

II Hematoma Major contusion without duct injury or tissue loss

Laceration Major laceration without duct injury or tissue loss

III Laceration Distal transection or parenchymal injury with duct injury

IV Laceration Proximal transection or parenchymal injury involving ampulla

V Laceration Massive disruption of pancreatic head

Advance by one grade for multiple injuries up to grade III Diaphragm


I Contusion Contusion

II Laceration 10 cm with tissue loss 25 cm2

Advance one grade for bilateral injuries up to grade III Chest Wall Grade Injury Type Description

I Contusion Any Size

Laceration Skin and subcutaneous tissue

Fracture < 3 ribs, closed; nondisplaced clavicle closed

II Lacerations Skin, subcutaneous tissue and muscle; > 3 adjacent ribs closed

Fracture Open or displaced clavicle; Nondisplaced sternum, closed; scapular body, open or closed

III Laceration Full thickness including pleural penetration; open or displaced sternum; flail sternum

Fracture Unilateral flail segment (< 3 ribs)

IV Laceration Avulsion of chest wall tissues with underlying rib fractures

Fracture Unilateral flail chest (>3 ribs)


V Fracture Bilateral Flail chest Advance one grade for bilateral injuries up to grade III

Lung


I Contusion Unilateral, 1 lobe

Laceration Persistent (>72 hours) air leak from distal airway

Hematoma Nonexpanding intraparenchymal

IV Laceration Major (segmental or lobar) air leak

Hematoma Expanding intraparenchymal

Vascular Primary branch intrapulmonary vessel disruption

V Vascular Hilar vessel disruption

VI Vascular Total, uncontained transection of pulmonary hilum

Advance by one grade for bilateral injuries up to grade III Hemothorax is scored under thoracic vascular injury scale


Appendix IV: Glasgow Coma Scale Eyes GCS score

Opens eyes spontaneously 4

Opens eyes in response to voice 3

Opens eyes in response to painful stimuli 2

Does not open eyes 1 Verbal

Oriented, converses normally 5

Confused, disoriented 4

Utters inappropriate words 3

Incomprehensible sounds 2

Make no sounds 1 Motor

Obeys commands 6

Localizes painful stimuli 5

Flexion/withdrawal to painful stimuli 4

Abnormal flexion to painful stimuli 3

Extension to painful stimuli 2

Makes no movements 1


Appendix V: Mangled Extremity Severity Score (MESS) Skeletal/soft tissue Injury Score

Low energy (stab; simple fracture; pistol gunshot wound) 1

Medium energy (open or multiple fractures; dislocation) 2

High energy (high speed MVA or rifle GSW) 3

Very high energy (high speed trauma + gross contamination) 4 Limb ischemia

Pulse reduced or absent but perfusion normal 1*

Pulseless; parasthesias, diminished capillary refill 2*

Cool, paralyzed, insensate, numb 3* *Score doubled for ischemia > 6 hours

Shock

Systolic BP always >90 mmHg 0

Hypotensive transiently 1

Persistent hypotension 2 Age

< 30 0

30-50 1

> 50 2


Appendix VI: Sample dictations Percutaneous tracheostomy The patient remained in the Intensive Care Unit with full hemodynamic and oxygenation monitoring. After informed consent was obtained from the patients health care surrogate, the patients head and neck were prepped and draped in sterile fashion. A timeout was called to confirm patient, site, and operation, as well as the administration of prophylactic antibiotics [class 2 case, review existing antibiotics, which usually cover this aspect] and the application of functioning Flowtron boots. A level of sedation, analgesia, and chemical paralysis appropriate for the procedure was confirmed. Local anesthesia (1% lidocaine with epinephrine) was infiltrated into the soft tissues of the intended incision. The skin incision was made sharply in the midline of the anterior neck, just cephalad to the jugular notch and inferior to the cricoid cartilage and continued with electrocautery through the superficial, investing, and pretracheal fascia, to include the thyroid isthmus. The anterior trachea was clearly visualized, to include the interspace between tracheal rings two and three. Critical care medicine colleagues then introduced a bronchoscope into the endotracheal tube, and the endotracheal tube and bronchoscope were simultaneously withdrawn until the transluminal light reflex was seen externally and the external indentation between tracheal rings two and three was clearly visualized endoscopically. A catheter-over-needle was then placed under direct bronchosopic vision between tracheal rings two and three, and the needle was removed. A guidewire was placed through the catheter and directed distally under direct bronchoscopic vision. The catheter was removed, and the tracheotomy was sequentially dilated using a Blue Rhino kit. A #8 Shiley tracheostomy tube with inner dilator was then passed over the guidewire and into the tracheal lumen under direct bronchoscopic vision. The guidewire and dilater were removed, the inner cannula was placed, and the cuff balloon was inflated. Mechanical ventilation through the tracheostomy confirmed end-tidal CO2. Bronchoscopy through the tracheostomy visualized the carnina. The tracheostomy shield was sutured to the skin in four corners with 0-silk, and a tracheostomy tape was applied. The estimated blood loss was 3 cc. No specimens were sent to pathology. The patient remained in the ICU. Percutaneous Endoscopic Gastrostomy Tube Placement

Following tracheostomy, our attention turned to assessment for suitability of PEG tube placement. The upper endoscope was introduced through a bite block into the mouth and directed endoscopically into the esophagus, stomach, and duodenum. The stomach was first suctioned of contents and then insufflated. The esophageal, gastric, and duodenal mucosa to the 2

nd portion were normal without evidence of inflammation, ulceration, or mass lesions. The

pylorus and angularis were normal. A retroflexed view of the cardia and fundus was normal. The stomach was maximally distended via insufflation, and a strong light reflex was visualized in the left upper quadrant. External indentation at the point of maximum light reflex was visualized endoscopically. 1% Xylocaine was infiltrated into the skin overlying the intended site, and a stab wound was made through the skin. A catheter-over-needle was then passed through the stab wound and into the gastric lumen under direct endoscopic vision. The needle was removed, and a guidewire was passed through the catheter and into the gastric lumen under direct endoscopic vision. The guidewire was endosnared and brought out through the mouth with the endoscope. The gastrostomy tube was then attached to the guidewire and and pulled through the mouth and out the anterior abdominal wall to the X cm mark. The external bolster was placed. The upper endoscope was reintroduced through the bite block and into the stomach to confirm proper button placement without mucosal blanching or laxity, absence of bleeding, and 360 degree mobility of the button. The stomach was suctioned, and the endoscope was withdrawn. The bolster was secured with 4 simple interrupted 0-silk sutures. The external gastrostomy tube


taper was cut off, and the port adapter was placed. The gastrostomy tube was sutured in a gentle curve to the anterior abdominal wall with several 0-silk sutures. The estimated blood loss was 3 cc. No specimens were sent to pathology. The patient remained in the ICU.


Appendix VII: Trauma Medical Student Guide 1. Trauma alerts

a. In the trauma bay, medical students are responsible for the H&P, bed request, and CT scan order form. As you become faster, you can also help fill out orders. The intern or junior resident should double-check and sign the H&P, CT scan request form, and orders after youve filled them out. All sections should be filled out on the H&P form, and if there are any assessments missing, call out to the resident to perform the exam you need. The H&P is structured as a learning tool. On the first page of the H&P form, in a separate boxed area, write the critical four: GCS, FAST, Hct, and SBP on presentation to ED.

b. If there is time and the situation is not as urgent, there is a role for medical students to learn and help with the arterial stick for blood, rectal exam, and Foley (interns role). Dont get too caught up in the paperwork or miss out, especially if there is an opportunity for procedure or learning (i.e. were performing an ED thoracotomy). Any patients who received a femoral arterial line will need to be changed over (in the ICU) to a radial arterial line as soon as possible. This is an opportunity for you students. Stay with the patient from the trauma bay until the patient reaches an assigned bed.

c. Start the tertiary exam once the patient reaches that bed. A tertiary exam is a full H&P/review of studies performed including history/mechanism, social/medical/surgical history/allergies, a full head-to-toe physical exam checking all bones and joints, neurologic exam, review of all laboratory trends (especially hematocrit, creatinine) and all radiology final reads, all consults final recommendations, and plan. If all final reads are done, then complete the tertiary, have a resident sign it, and place it on the chart. If there are a few final reads pending still, mark the area that needs a read with a different color pen or some type of symbol like a star (*) and put it in the box.

2. Consults

a. Especially during nights, a student should be with the junior or consult resident on all

consults or admissions. It is a learning opportunity and part of your rotation objectives to learn about the presentation, evaluation, and work-up of the acute abdomen. For any acute abdomen, such as appendicitis or cholecystitis, make sure to perform your own physical exam.

b. Treat trauma consults exactly as you would a trauma alert. You can help the junior with the H&P, orders, and bed request.

c. Start the tertiary right away once the patient is admitted.

3. Trauma night call

a. Night call begins at 6 PM on ward 10-5 with hand-off rounds between the day and night

shifts.

b. Student night call involves being present at trauma alerts, for consults and ward emergencies, and in the operating room. Students not assigned to the trauma service for their four week rotation are not expected to write trauma service progress notes.

c. A student should scrub on every case at night. Likewise, a student should be with the junior resident at all times to learn and assist. Go to all trauma alerts. Help complete any pending tertiaries or start tertiaries on any trauma admissions.


d. Trauma call is a good opportunity to perform procedures. Earlier in the year, interns will

want to perform laceration repairs and chest tubes to gain experience, but later in the year, residents are happy to assist you in laceration repair, incision and drainage of abscesses in the ED or on the medicine floors. When you begin call, let the intern and junior/chief know that youre interested in learning, helping, or doing procedures. The more available you make yourself (instead of hiding/sleeping), the more opportunities you will find and the more opportunities the residents are likely to give you.

4. Multidisciplinary conference

a. Monday conference is at 7:30 AM, and thus, we round at 5:30 AM on Mondays. Friday

conference is at 8 AM.

b. This conference reviews every patient on the service in the setting of all available resource representatives (surgical team, nurses, PT, OT, dietary, rehab, social work, case management). The purpose is to facilitate patient progress on the care pathway to recovery.

5. Daytime

a. A student should scrub in on every OR case and every ICU trach/PEG procedure.

Learning takes priority over paperwork, but the floor work is also an opportunity to learn and be part of the team.

b. On morning rounds, medical students should enter the room, perform a focused exam of heart, lungs, abdomen, general neuro status (mental status, extremity movement), and pulses. Wounds should be inspected in the context of dressing changes, and drain output should be assessed. orough process can tend to deteriorate into just a wound check. Another good skill to learn (that really applies more to the interns) is assess what is still attached to the patient (central lines, IVs, Foley catheters, drains, chest tubes and NG tubes) and to figure which can be removed/discontinued.

c. It is a good idea to have a pair of scissors in your coat/scrub pocket, extra 4x4 gauze,

and paper tape. At the very least, carry around the scissors and then rely on the rounding cart for the gauze, tape, Kerlex, etc. Medical students are also responsible for keeping the cart stocked with gauze, tape, Kerlex, abd pads, and 1L normal saline bottles. Be sure to clean your scissors after each use.

d. After rounds and conference (on Mon/Fri), help the intern or resident finish basic and

minor procedures before going to the OR (if there is time). This includes pulling drains, chest tubes, NGT/Foleys (which can also be done on rounds), wound debridements, VAC dressing changes, laceration repairs, or delayed primary closure of wounds. One thing to note about drains, our surgical drains (clear, stretchy tubing) can be pulled right out. The drain you need to be careful of is the pigtail catheter which is usually a blue tubing these need to be unlocked and the suture/tie cut before pulling the pigtail drain out, because that suture is what is preserving the pigtail shape inside the body; if the suture is not cut, the pigtail will shred its way through tissue as youre pulling it out. If you are at all uncertain about a drain, ask for help.

e. The day should follow this order, from highest to lowest priority:

i. Discharges are first priority. Medical students primary role in helping to move

patients to discharge is completing the tertiary.


ii. Calling consults. Residents should not have you call new consults. It is not appropriate, and these should be resident-to-resident communication. If the workload is tremendous, then it may be acceptable to have a student call a service for a follow-up recommendation. Just make sure that you present like a resident would dont give them any hint that youre a medical student.

iii. Procedures (mentioned above) iv. Write pre-op notes for patients going to the OR in the next day or so. This

includes:

Pre-op diagnosis

Planned procedure

Attending surgeon

Pre-op work-up meaning labs especially CBC & Coags, chest x-ray, EKG, any other work-up for surgery (i.e. barium enema before ostomy takedown)

Consent on chart

H&P on chart

Physician pre-op orders a. NPO p MN with IVF b. Blood products (T&C) or at least a T&S on almost every patient c. Antibiotic on-call to OR

i. Kefzol 1g for skin ii. Vancomycin 1g if ceph allergic iii. Cefotan 1g for colon iv. Timentin 3.1g for complex bowel/biliary or suspect perf

viscus v. Cipro 400mg/Flagyl 500mg if pen-allergic for bowels

d. Beta-blockade i. Atenolol 50 or 100mg po x1 or metoprolol 5-10mg IV on

call to OR ii. Hold only if HR < 55 or SBP < 100 iii. For outpatients, this should be started in clinic.

e. Diabetics on insulin need adjusted dose (ask the resident) f. Chronic steroid therapy needs pulse hydrocortisone 100 mg IV

on call to OR and 50 mg IV q8h for the first day post-operatively, then taper to home dose. 4 mg hydrocortisone = 1 mg prednisone

v. Do post-op checks on any cases you were scrubbed in


Appendix VIII: Tube thoracostomy (chest tube placement) Initial steps 1. Obtain consent for (right or left) tube thoracostomy and all indicated procedures. 2. Have the nurse get a chest tube set-up and Pleuravac set-up at the bedside. 3. Order morphine 2-4mg IV x1 for procedure and have the nurse administer this. 4. If the patient is especially anxious

gator_trauma_manual final ay 2009-10

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