IS it time to review the systematic approach we take for the early management of trauma?
The early management of severe trauma (EMST) protocol in Australia was adapted from the US Acute Management of Severe Trauma (ATLS). The American College of Surgeons developed ATLS in the 1970s in response to a need for a systematic approach to the early care of patients “suffering major, life-threatening injury”.
EMST focuses on the threat to life first, and guides the provider through a logical sequence of assessment and treatment.
However, this logical system seems to be used increasingly for every patient with trauma, morphing into a robot-like repetition of tests that bypass clinical logic.
My doubts about the way EMST is used were brought into sharp focus while I was recently working in the emergency department (ED). When I arrived in the ED, I found a school-age child lying on a trolley, neck in a rigid collar, looking scared.
He had fallen from his bicycle, hitting his face on concrete, and had been stunned for a few seconds but remembered the event. He had vomited shortly after.
Our hospital — which is not a trauma referral centre — recently started a team call system for surgical emergencies, including trauma. By the time I arrived, the primary and secondary surveys for this child had been completed and he had a cannula in the cubital fossa.
He was fully awake and said his neck was not sore, so I took off the collar, to his relief. His face was sore and grazed, and he had lost a front tooth. Luckily, Dad had brought the tooth (a permanent one) and we had it in a jar of milk.
At that point, the senior surgical registrar proposed doing a cerebral computed tomography (CT) scan on the basis that the child had hit his head and vomited. He also wanted a focused abdominal ultrasound.
As the boy had lost a tooth and had swallowed blood, the vomit was not such a worrying sign. He was fully awake and had hit his face but not his head. I felt his belly, which was not tender and had no external signs of injury.
I decided to spare the child the radiation of a brain CT for no good indication, preferring to observe him in the ED.
It was then that I remembered the tooth — an upper incisor dislodged with its root. We rinsed out the socket and our ED registrar re-implanted it, saving the child the need for a future cap.
We observed him further, contacted the paediatric dentist at the local children’s hospital, and later transferred him for a review of the tooth and assessment for any imaging that might be necessary around the face.
We saved him a CT scan, as well as a lost tooth, and the hospital unnecessary expense.
And this is when I reflected on how the EMST protocol is administered. At what stage did EMST become a series of unnecessary tests for the less severely injured?
With growing concern about overtreatment and overdiagnosis, a rational application of EMST principles can save patients from some unnecessary testing.
This child did not need us to save his life. But we saved his smile.
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.
Posted 25 February 2013