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| No. 20 | 
May 23, 2008, 09:06 AM
 Re: Emergency Room vs. Motorcycle Accident Patient Originally Posted by mwboswell  Careful here when you say "standard" then that means that all places that either don't do it or don't have the capacity aren't providing "standard" care.... CT is NOT the standard of care for spines at this time. It is an adjunctive diagnostic tool. The history and clinical exam are the standard (meaning everyone gets this), the plain films or CT are based upon your findings or further investigation. I refer you to research the Canadian C-Spine rules or the NEXUS criteria for imaging of the spine in trauma. These tools have been validated and thoroughly researched over the years, and Mechanism of Injury alone is not criteria for imaging the spine.....
Do we xray and CT more than we should - definitely.
Do some clinicians use xrays and CTs in lieu of poor assessment and inadequate clinical decision making -YES (I am guilty of this sometimes also I admit)....
But does that make it acceptable to connotate xrays and CT's of the spine as "standard" - NO
All I'm saying is just be careful to not get in the trap of thinking what is "standard" versus not.
In my level I, university/teaching, trauma center, 115 bed ER with 180,000 ER visits/year - this definitely is not standard care.
Hope this helps!
-MB You MUST admit that this MOI.....MCC rollover with significant road rash should and would have been considered a Trauma Standby at the very least until the secondary assessment as completed and then downgraded from that point.This should have been started as a Trauma Standby. (This case will be brought up in review within the trauma system) A CT scan is both common and needed in this situation but the EMD chose not to based on his assessment. If a Trauma Surgeon would have been entitled to assess this patient he/she would have ordered a CT SCAN, but they weren't because of the designation. To just Cover his butt, he should have ,since ejection from an MCC regardless if a helmet was used is of concern for internal trauma. Sure the disposition is after the fact, but you must admit...if it were your son.......I would think a simple CT to rule out would have been something you would have wanted. I'm not certain what level trauma center you work at or had worked....but I think the trauma designation would have been made in a Level II, Level I Trauma Center based on MOI alone. Patterns of injury with MOI >>>Ejected over the motorcycle, strike fence and chest on handlebars, internal big time injury, lower legs may be trapped, cranial and cervical injuries, inside leg fractures and soft tissue injury, ect. This patient would have been made a Trauma Standby @ the very least @ my ER is rated amongst the top 100 in the nation. This EMD was remiss.....plain and simple. We have a new state of the art 65 bed trauma center and see over 190,000 a year....EMS call, designation to Trauma STandby, radiology to CT, then downgraded from there.....Good Trauma Care..plain and simple!  | | Advertisement Sponsored Links | | | | No. 21 |
May 23, 2008, 09:15 AM
Re: Emergency Room vs. Motorcycle Accident Patient Originally Posted by TraumaNurseRN We have a new state of the art 65 bed trauma center and see over 190,000 a year....EMS call, designation to Trauma STandby, radiology to CT, then downgraded from there.....Good Trauma Care..plain and simple!
...how about FAST exams?
You could use that instead of all the radiation as a first level screening tool....plus less risk for complication during intrafacility xport. Question: Do you do your Trauma CT's with or without oral contrast???
-if you do them "with" how do you justify giving a pt PO contrast who might have a perforation or internal disruption???
-if you do them "without" oral contrast, how do they see hollow organs on the scans???
...how about angio for vascular integrity?
| | No. 22 |
May 23, 2008, 03:47 PM
Re: Emergency Room vs. Motorcycle Accident Patient Originally Posted by mwboswell ...how about FAST exams?
You could use that instead of all the radiation as a first level screening tool....plus less risk for complication during intrafacility xport.
Question: Do you do your Trauma CT's with or without oral contrast???
-if you do them "with" how do you justify giving a pt PO contrast who might have a perforation or internal disruption???
-if you do them "without" oral contrast, how do they see hollow organs on the scans???
...how about angio for vascular integrity?
We do both, depends on the patient and the Surgeon or EMD. It's a risky business you and I both know. We do have bedside US too. I guess my first concern was the initial assessment as to why this kid wasn't made a trauma standby at the very least.
| | No. 23 |
May 23, 2008, 04:00 PM
Re: Emergency Room vs. Motorcycle Accident Patient
Fast exams have become a standard assesment tool during a work-up in our ER. And the MOI of speed, and becoming thrown from vehicle would make him a trauma ALERT!
We do not give oral contrast for abd/pelvic trauma CT's . Non-trauma yes, and sometimes rectal contrast....a ER favorite!! Any decent CT scanner can give enough of a clear image that they can see abnormal vs normal.
| | No. 24 |
May 23, 2008, 04:04 PM
Re: Emergency Room vs. Motorcycle Accident Patient Originally Posted by MacDaddyERRN Fast exams have become a standard assesment tool during a work-up in our ER. And the MOI of speed, and becoming thrown from vehicle would make him a trauma ALERT!
We do not give oral contrast for abd/pelvic trauma CT's . Non-trauma yes, and sometimes rectal contrast....a ER favorite!! Any decent CT scanner can give enough of a clear image that they can see abnormal vs normal.
agree
| | No. 25 |
May 29, 2008, 06:15 PM
Re: Emergency Room vs. Motorcycle Accident Patient
a CT wouldve taken all but 10 minutes just to make sure nothing is cooking. I know we do abuse radiology at times, but if this isnt a need for a cat scan then what is?
im really surprised that they were so lax with his treatment, i work in a level 2-3 and we see silly mva accidents where people come out without a scratch yet they dont even remove the collar until the cat scan is back.
| | No. 26 |
May 29, 2008, 09:09 PM
Re: Emergency Room vs. Motorcycle Accident Patient
While I do think he probably should have gotten a CT'ed from head to pelvis due to MOI, not every road rash wound needs to go to OR for debridement. Most do just fine with a scrub. Yeah they hurt like hell but I've been on both sides of this and when I was on the side of the pt is when I learned to wear my protective gear because it hurts to clean your road rash. I'm not excusing what happened, I'm just saying that maybe it was your typical roadrash and some lidocaine jelly before the scrub would have been sufficient. I find it hard to believe no MD or NP/PA examined you son, perhaps he had a mild CHI and doesn't remember.
Again, I'm not excusing poor treatment, just playing devils advocate and seeing things from more than one POV. I hope he recovers well and as a biker I hope he doesn't quit riding because of this experience. I also hope he will use this as a learning oppurtunity as I did and wear all his protective gear.
| | No. 29 |
Jun 01, 2008, 12:10 PM
Re: Emergency Room vs. Motorcycle Accident Patient
I am going to have to say I agree there is no excuse for not CT scanning this person. I in the last 20 years have seen a lot. In the more recent era of CYA medicine we scan MVC victims with barely a scratch who have a c-collar in place.
I will admit though on any given day you have to take in to account which ED physicians are working, who your trauma doc's are and who are the radiologists. The various combinations change what you can and can't do not only with trauma, but with other types of pt's as well. One combo may get you a lot of CTS one day and barely any the next with a similar patient mix. It only frustrates us and makes giving good quality care difficult,
Rj
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