how to be a great trauma intern - university of washington how to... · structure • trauma team...
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How to Be a GREAT Trauma Intern
Harborview Medical Center
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Harborview Trauma Center
• Receives all major trauma from WA state as well as neighboring Alaska Idaho and Montana
• Transfers from Rural Hospitals
• Field Responses Airlift
• Receives all major trauma from WA state as well as neighboring Alaska Idaho and Montana
• Transfers from Rural Hospitals
• Field Responses Airlift
Harborview Trauma Center
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Logistics
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Structure • Trauma Team is: • Emergency Medicine Attending • “Trauma Doc” (TD)
– second year Emergency or Surgery resident who oversees all trauma and run the codes
• Trauma Interns – 2-5 interns form various residencies – Emergency, Surgery, Family Medicine, OB – from HMC/UW, Virginia Mason and Swedish
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Other Fishes in Bowl
• Surgery R3 will be the general surgery consult • sits next to TD in fishbowl
• Ortho resident often in ED fishbowl too • Modified trauma codes have Surgery Chief and R3 at
work up • Full trauma codes have whole Surgical Team and
Anesthesia
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Trauma Algorithms
• There are Committee based Evidence Based Medicine ( EBM) algorithms, updated within last year
• There are 2 websites to access the Trauma Algorithms – 1. WIKI (hmced.org)
• wiki also has all other info @ running the ED – 2. OCCAM site (occam.hsl.washington.edu)
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WIKI • www.hmced.org • Lists all information about Harborview ED • Trauma Care section has all trauma algorithms
and references to the EBM literature • Training and Educational section has
– procedural videos – power points on Emergency Medicine
didactics – interactive educational games
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OCCAM (Online Clinical Care Algorithms nd Messages)
• OCCAM is a UW website created by the UW faculty (occam.hsl.washington.edu)
• Lists the most up to date committee based/EBM algorithms for proper work up and treatment for patient care
• Many of these relevant to Emergency Medicine are loaded directly onto the WIKI
• Can access the OCCAM site on side bar of WIKI and find them imbedded in the WIKI
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Trauma Algorithms
• READ the Trauma Care section of WIKI • Know what constitutes major and minor trauma • Know what constitutes high and low risk mechanism • Go over:
– C Spine Clearance – Indications for Head CT – Blunt and Penetrated trauma algorithms – How to Document and enter Orders
BEFORE YOUR FIRST DAY
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Trauma shifts what your day will be like
Will be a mixture of major and minor trauma Be able to change gears from loping along to very
efficient multi tasking
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Minor Trauma
• Lacerations • Low speed MVAs • Assaults • Ground Level Falls • Low Level Falls • Minor Burns
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Minor Trauma
• Sign up for your patient on Firstnet – So team knows patient claimed
• Undress everybody • ABC - > exam head to toe and back • Then present to Trauma Doc/Attending • Order Xray and labs • Go over plan with Nurse • Don’t forget analgesia
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After Orders are entered
go talk to Nurse and verbally go over plans and orders
This is vital muy importante for timely care
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Major Trauma
• All high speed MVAs • MCAs >20mph or separation from
vehicle • Falls >20ft adult >10ft kids • Auto vs Pedestrian or bicycle • Penetrating Injuries • Head injury with altered mental status • Major Burns/Inhalations
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Major Trauma
• All Interns to medic arrival – Unless assigned to other tasks
• Know your role
• One Intern should enter orders as TD and Attending
decide work up
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Major Trauma • Get physical process done • Help Undress the patient • Help Roll the patient • Femoral ABG • Place IVs/Hang Fluids as needed • Put in Orders • Help Assess extremity damage • Help Splint unstable limbs • Do ABIs
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“Trauma Labs”
• Includes: CBC, Chem 7, PT/PTT, Amylase, BAL • Extra order for lactate and serum pregnancy • Extra order ABGs, CO, Troponin, CK, LFTs and
Lipase • Pediatric trauma labs have LFTs • Extra order for Type and Cross • DONT order EHP (emergent hemorrhagic panel)
except for massive transfusion protocol ( its very expensive)
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Trauma Xray/CT orders
• Most Commonly ordered for Major Traumas • XR Trauma Series • CT Trauma Torso w/ T/L Spine reconstruction • CT Trauma Head W/C Spine • or • CT Trauma Abdomen/Pelvis with T/L spine reconstruction • XR Extremities as indicated
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CT Trauma Panscan not yet available - but soon to replace separate orders ( EBM indicates this is emerging standard of care)
Trauma Xray/CT orders
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Major Trauma • Understand that Communication is Key • Report all findings out loud to TD • All Communication through the TD • If hear important information -> share it • Go get Nurse to help bring meds to bedside if
needed • Call Consults if TD need it • Ask the MAs for equipment requested or inferred
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Wound Care
• Clean off all wounds well to inspect for underlying lacerations
• Use long acting local anesthesia if dept busy • Close wounds within 6 hours • Make sure DT given if needed • Make sure Attending sees procedure
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Consults • Some TDs want to call all consults- other delegate to
the interns • Know the ORTHO minor trauma list - (on WIKI)
– Some injuries follow up w/primary care • Craniofacial (CF) is the pager for all facial trauma-
– covered alternating by: Plastic/CF and ENT • “SPINE” is the pager for all spinal injuries
– covered alternating between Neurosurgery and ORTHO
• OB/GYN wants to be paged on all pregnant trauma patients
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Close the Loop
• Discuss Lab and Xray findings with TD and Attending • Reassess patient • Consults
– Occasionally consult resident will tell a single person the plan
– Make sure it gets back to TD and Attendings ASAP
• Disposition
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Disposition
• All patients need an assigned provider and time frame in which to see them
• Often a consult service clinic • If not, follow up with PCP • If no PCP, get After Care Clinic appt and give out
community clinic list • Put in referral forms as needed • Recommend Rx for all
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Disposition
Make your life easier
Start discharge forms as soon as you have a good idea of plan
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Documentation
• Develop a good full trauma exam document • Describe all injuries succinct and exact • Pertinent negatives very important • Send the chart to the primary/first ED Attending • Get your charts done that day
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Trauma Doc needs to know everything
The Attending does too
Hopefully TD is keeping the Attending abreast of everything
But if super busy make sure Attending knows
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Take it ON • Know the Protocols • Understand your Role within the team • Full exam on everyone • Communicate with Nurses, TD, Attending • BE A TEAM
LEARN A LOT and HAVE FUN
Its just a shark….
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Elizabeth M Dorn MD, 2013