“My craniotomy trumps your closed fracture!”
Well, you won’t hear those exact words, but the fact is that there are many such behind-the-scenes issues that can cause tension between hospital staff—especially if your institution does not have a dedicated orthopedic trauma room.
Dr. Philip Wolinsky is a traumatologist with the University of California at Davis Medical Center who set out on a mission: do a literature review and establish the benefits of having an orthopedic trauma room. The goal was to provide concrete information, both for surgeons whose hospitals may be debating the merits of their existing trauma room, and for those who want to convince their hospitals to add one. Dr. Wolinsky presented his findings at an instructional course lecture at the 2011 meeting of the American Academy of Orthopaedic Surgeons.
He notes, “Trauma rooms have changed the way orthopedic trauma surgeons practice. In the past, an emergency case such as a craniotomy could get into to the OR quickly and the elective cases were scheduled when they could be. But what to do about the patient with a broken tibia? It doesn’t have to be done post haste, but it can’t wait six weeks…those cases were traditionally hard to get on the OR schedule. Yes, they could be done in the middle of the night or during the day; but for the latter option you would have to bump other elective cases or cancel clinic, neither of which are good options for the surgeon or patient. As a result of this and other deterrents, trauma was not a popular career choice for orthopedists.”
Dr. Wolinsky, a reviewer for the Journal of Orthopaedic Trauma, says, “Now that trauma rooms are growing in number things are quite different. For example, if you look at the number of applicants to trauma fellowships, they have skyrocketed over the last three or four years. Trauma has become a popular career path, to a large extent because adding a trauma room provides numerous work benefits—not to mention that it is easier on one’s home life. When I first started as a resident there were young surgeons covering trauma just so they could get their practices up and running. In effect, they were using trauma coverage as a bridge and then once they became established as, say, a sports medicine specialist, they would say, ‘I’m not getting up in the middle of the night anymore for cases that aren’t real emergencies. No more trauma call for me.’ Then you get into the problem where the hospital is routinely left with inexperienced surgeons because the veterans are opting out. Obviously, that is not ideal for patients.”
Back to those semi urgent cases. Dr. Wolinsky states, “If you have a patient with a broken tibia, but you do not have a trauma room then the person has to stay in the hospital until you can get OR time. Let’s say I am a sports medicine specialist who has to cover call—and my week is already scheduled with office hours, elective cases, etc. If someone with a tibia fracture comes in you can’t do it the next day because the elective time is booked. You can try to do it after hours but that is when the hospital is less staffed…and you are competing with appendectomies, neurosurgery cases, etc. And guess whose non-urgent tibia fracture is way down on the list?”
“That surgery is either going to carry over to the next day or the hospital is going to call you at 3am and you have to do the procedure then. You shake your head and say, ‘Hey, I’m only going in to do this surgery at 3am because it’s convenient for the hospital. I’m not at my best and that isn’t the best for the patient.’ It’s a spiral…and you don’t have to look far to see why trauma call isn’t popular.”
U.S. Navy photo by Mass Communication Specialist 2nd Class Chad A. Bascom/Wikimedia Commons
Dr. Wolinsky, who says he would “never ever” work at a hospital that didn’t have a dedicated orthopedic trauma room, details, “Hospitals claim that trauma care doesn’t generate income, but a 2008 Journal of Orthopaedic Trauma study conducted by Heather Vallier, M.D. on a level one trauma center demonstrated that in fact trauma was generating income for the hospital.”
Beyond this talking point, there are the very real issues of staffing and equipment that arise when there is no orthopedic trauma room. “Ideally, you would have surgeons and nurses who are interested in and accustomed to these cases. And the knowledge level/experience of the staff is important as well…you really need people who know how to locate equipment and which piece goes where. This is especially important now that cases are getting more complicated and the equipment is often more involved.”
Elaborating, Dr. Wolinsky notes,
No one wins when you’re doing a case at 3 am with a team that can’t find the equipment and isn’t up to speed on the implants.
“What usually happens is that the equipment is taken away at the end of the day to be cleaned. And the night staff, individuals who cover all specialties, may not know how to find what you need in Central Supply…your case just got longer.”
So what else can trauma surgeons point to when talking to reluctant hospital administrators? Dr. Wolinsky: “A 2006 study by Timothy Bhattacharyya, M.D. showed that the addition of an orthopedic trauma room resulted in fewer elective cases being bumped, a 72% reduction in hip fractures done after 5pm, and resulted in decreased operative time and a reduction in complication rates.”
Which brings us to what definitely makes (anyone) sit up straight…liability issues. “Trauma patients are often young men who engage in risky behaviors, and whose situation may involve drugs or alcohol. Compared to the elective surgical population, these folks are often times underinsured or uninsured. And while it has not been documented that these patients are more likely to file a lawsuit, the fact is that surgeons worry about litigation. This is yet another reason to have a dedicated room where you can get these patients treated expeditiously and with a knowledgeable staff.”
“Mr. Jones is in room 12.” No, he’s not…and he never was. Dr. Wolinsky delves into the details: “Booking patients into an OR can be mayhem at times. With a ‘regular’ OR, the surgeon has a set day/time by which he or she must book a patient. If they don’t then the time slot is given away; the idea with a trauma room is that the time is more flexible. Without a trauma room a patient may come into the ER at 4am on a Monday, but our OR time gets released at 6am (meaning that you only have until 6am Monday to book cases for that day). There have been times when people booked fictitious patients into a room in order to hold it open—and then put real people in later. With a dedicated orthopedic trauma room, however, there is no danger of this. Your day will change based on what comes in the door…you have the flexibility to keep changing the cases.”
Dr. Wolinsky’s article, which has just been accepted for publication by the Journal of Orthopaedic Trauma, is balanced. He notes, “There are potential disadvantages to having a trauma room. One issue is that it may be easy to put all cases off until the following morning; this is especially the situation when you have a clinical problem that is unresolved in the literature. For example, we do not know definitively if an open fracture needs to go to the OR immediately. Is it the timing of the debridement or the quality that makes a difference as far as getting an infection…is 2am better than 7am? It can be tempting to say, ‘Well, I probably don’t need to do anything in middle of the night.”
Taking a global perspective, Dr. Wolinsky says, “If someone with a low grade open fracture comes in at 2am you can either operate in the middle of the night or first thing at 7:30am.”
“If I choose to operate in the middle of the night it’s not clear if that is any better for that patient’s outcome. But I do know that if I do it in the middle of the night I will be fatigued the next day and by 3 or 4pm I am burning out my daily reserve of energy. If I look at this issue philosophically I think, ‘Maybe I am helping one person in the middle of the night, but I’m probably not helping people much the next day.’”
If I keep doing this I will reach the point where I say, ‘It’s not worth it.’ And if all trauma surgeons were to do that we as a country would have a serious problem.”
Imagining himself in a patient’s gown instead of a white coat, Dr. Wolinsky says, “There are a lot of people who come in at midnight with problems that we know can wait until 7am. If you were the patient, wouldn’t you want the guy operating on you to be the one who has had a good night’s sleep, and where the nurses are prepared and all of the right equipment is in place? I would want the 7am surgeon.”
