Trauma Report

[SanDiegoEmt7]

I have talked to many people who have different ways that they give report to a trauma teams in the ED. I am aware of how to give a radio report (full report and short/destination reports) I use to always give a report similar to my radio reports but I have been aware of other formats.

Anyone have an favorite format or acronym, specific to trauma team reports, that you like to use?

 

[BLSBoy]

Go slow.
Start from the top.
Pt demos, what happened, how they were on your arrival, what you did, how that affected them, final pt assessment.
Very short and simple.

 

[Jon]

Go slow.
Start from the top.
Pt demos, what happened, how they were on your arrival, what you did, how that affected them, final pt assessment.
Very short and simple.

Pretty much what I was gonna say, AJ.

Who: Patient Name, age/sex. It may seem hackneied, but I usually start with "This is Bill Jones, 59"
What/Why: Why I'm at the trauma center: "Restrained driver in a 2 car MVA, with chest pain post airbag deployment"
Where: Brief description of the scene, if applicable. Remember, all the trauma team has to look at is the patient... YOU must paint the picture of the mechanism of injury: "Moderate speed T-bone MVA, Mr. Smith was restrained driver, airbags deployed, struck driver's side of other car head-on.
When: How long ago. Also how long my transport time was.

After you paint the inital picture, then you go though your exam... head to toe, noting issues you found. "(-) LOC, (+) chest pain, 12-lead EKG looks normal, here's a copy, Abdomen soft non-tender, Also complains of 7/10 knee pain, nothing on exam. No other complaints.

What you did for the patient - interventions, their responses, etc.
"Pt has an 18ga Left AC, labs drawn, NSS TKO. Vitals remained stable throughout transport... most recent set of signs is: _____

"Any other questions?"

Does that seem to make sense?

 

[exodus]

Neither of you said anything about pt history if known, or anything about last intake?

 

[terrible one]

Neither of you said anything about pt history if known, or anything about last intake?

Full Hx, Rx, Allergies given upon arrival.
Last Intake? that never goes into my radio report

 

[Veneficus]

Don't use too many words.

Pt age, what happened, anything onscene that seems important.
this gives the team all they need for a mechanism and index. Plus since they were not onscene that inf gives them something they cnnot see for themselves. (other death, extrication, multiple victiems, etc.)

Everything else is going to be reasessed in extreme detail and most of the time nobody is listening past your first 30 words in my experience.

If the patient is by definition a "trauma" but probably doesn't warrent immediate surgical or intensive therapy, you can give report all day. (aka socialize)

 

[exodus]

Uhm, He's talking about giving a report to the trauma team at the ED. He said he's good at the radio report.

 

[Veneficus]

I understood that. It doesn't change my reply.

 

[exodus]

I understood that. It doesn't change my reply.

So when you give a turnover to the trauma team in the trauma bay you won't tell them the last time they ate?

 

[BLSBoy]

So when you give a turnover to the trauma team in the trauma bay you won't tell them the last time they ate?

Nope. Never have, unless they vomited their fresh food all over the place, at which point I try to ID it, and ask them their best guess.

 

[CAOX3]

I dont include last PO intake on a radio report, however it is important information to be included in your MD report if an operating room is in someones future.

 

[Veneficus]

Nope. Never have, unless they vomited their fresh food all over the place, at which point I try to ID it, and ask them their best guess.

+1

Inevitably a trauma patient (especially a severe one) ate just recently. Otherwise it would make intubating and surgery uncomplicated and we simply cannot have it easy.

There is also frequently various amounts of alcohol consumed.(liquid courage)

 

[BLSBoy]

And I will be honest, last oral intake is the last thing on my mind.
What is gonna kill him in the next 5 min?
What can I do to prevent that?
What is gonna kill him in the next 10 min?
What can I do to prevent that?

Thats about what is going through my mind.
Couple that with the fact I KNOW that this person needs hot lights and cold steel, not a paramedic means I am gonna have as short of a pt contact time I can have.

 

[CAOX3]

And I will be honest, last oral intake is the last thing on my mind.
What is gonna kill him in the next 5 min?
What can I do to prevent that?
What is gonna kill him in the next 10 min?
What can I do to prevent that?

Thats about what is going through my mind.
Couple that with the fact I KNOW that this person needs hot lights and cold steel, not a paramedic means I am gonna have as short of a pt contact time I can have.

Airway obstruction and aspiration cant kill you?

 

[BLSBoy]

Airway obstruction and aspiration cant kill you?

I can secure an airway in 15 seconds or less, and it is one of the first things done on a major, multi system trauma.
It isn't a factor after its secured.
If they cant talk, I dont know.
If they are able to secure their own airway, they say they are gonna vomit, they got rolled/suctioned/zofran if I have the time.

 

[Veneficus]

a moment of pause

The trauma patient: This includes everyone from the person who "stubbed their toe" on the table to the person who had an Mi prior to skydiving into his boat, running aground getting ejected into a convertible and the Toyota accelerator propelling him down the freeway while hypoglycemic before he is shot 5 times in the chest and rolled the vehicle; ultimately crashing unrestrained with deployed airbags into a tree.

So allow me to break this down a little.

Some of these patients do not need a hospital.
Some will need a hospital and never go.
Some will need an emergency department.
Some will need a surgery.
Some will require not only a damage control surgery, but an ICU stay and multiple surgeries and rehab to return to some level of normal function.

So let's assume for a minute that all providers are capable of and perform a proper history and physical exam that is required for the level of intervention they are going to provide.

Is the fact the patient is NPO for 24 hours or who got into a beer and pizza eating contest 5 minutes ago going to have immediate impact? How much?

If a basic finds a patient (of any type of injury level) who might vomit, isn't positioning the patient prior to and suctioning after vomiting going to be the intervention?

Is a paramedic going to choose to intubate (with or without drugs) based on the ability to maintain an airway or because somebody might aspirate? It becomes a risk/benefit analysis, there s no one size fits all answer.

The same thing for the doc at the ED. It is simply not practical or good patient care to intubate and ventilate every patient who "might" aspirate and occlude an airway.

Hopefully if they are going to surgery they will be intubated. Maybe there will be a cric or some other airway put in place?

No matter how good of assessment you perform, no matter what your findings, every provider as the patient progresses through the system is going to reassess them. It is how oversight is reduced, how changes over time are detected, and certain finding are more important than others for different providers. (go ahead and ask the orthopod if they want to see the EKG)

The whole of the Prehospital assessment is not important in the hospital. There is a lot to do and a lot of people talking on a patient who has a trauma team response, being concise is highly valued. After cutting every piece of clothing off of a patient I don’t need anyone to tell me they are a male/female of approximately X age or any other readily apparent finding. If I see an angiocath hub sticking out of the chest, I will probably assume somebody thought there was a pneumo, not that they just attempted the worst IV stick in history. Moreover, since a pneumo can develop with time, it will likely be reassessed multiple times regardless of Prehospital findings.

Other treatments or requirements can be just as obvious. Like when you come in bagging a pt., doing chest compressions, or your interpretation of the heart rhythm when your monitor screen is facing me. Likewise I don’t want to hear your gloves are on and the scene was safe.

When giving or receiving a report, it should be accurate, pertinent, and concise. Reciting the NR assessment check off sheet is only useful for NR test proctors.

I wish my responses here could be the same, but inevitably some cretin would accuse me over overlooking some detail applicable on Feb 29 when the moon is full, the tide is low, there is a solar flare from a distant galaxy, the storm on Jupiter intensified, and a used car dealer didn’t cheat a customer.

 

[SanDiegoEmt7]

I wish my responses here could be the same, but inevitably some cretin would accuse me over overlooking some detail applicable on Feb 29 when the moon is full, the tide is low, there is a solar flare from a distant galaxy, the storm on Jupiter intensified, and a used car dealer didn’t cheat a customer.

Haha this is awesome!

But anyways, just to summarize, how does this sound?

1) Patient Demographics
2) Mechanism of Injury, with any pertinent findings on scene
3) Assessment- only injuries and abnormal vitals
4) Treatments- with any changes
5) Final assessment

All steps being as concise as possible

 

[wyoskibum]

Sounds good, but.....

Haha this is awesome!

But anyways, just to summarize, how does this sound?

1) Patient Demographics
2) Mechanism of Injury, with any pertinent findings on scene
3) Assessment- only injuries and abnormal vitals
4) Treatments- with any changes
5) Final assessment

All steps being as concise as possible

I don't know how it is in San Diego, but I have found that some of the trauma centers, the receiving MD may be interested in 1 & 2 only. It may be specific to a particular MD. Just don't take it personally if they ignore you.

 

[LondonMedic]

So when you give a turnover to the trauma team in the trauma bay you won't tell them the last time they ate?

Why?

1. If they're sick and need intubating, they will get intubated regardless.
2. If they're not sick and don't need intubating there's plenty of time to sweat the details later.
3. Similarly, if they're sick they need the trauma team to be assessing and treating them, if they're not listening to you describe their breakfast and history of tonsillectomy when they were eight.
4. The anaesthetist will ask them anyway. The sister will ask any family or friends.

I find that 'MIST' works just fine - heavy on M and T, easy on I and S. But you guys are professionals and should be trusted to work out what needs to be said and when.

 

[MrBrown]

What makes a trauma team any different than any other group? I don't think anything makes them different to be honest, they still require the same information as any other person Ambulance Officers handover to.

They are going to ask pretty much all the questions and do the assessments you already have so there is no need to go on at nauseum about these things because its pointless.

A nice and simple format taught by Auckland DHB Trauma Services is MIST

- Mechanisim of injury
- Injuries noted
- Scene treatment
- Treatment response

To use an example from one of a job earlier tonight (probably not the best)

"<tongue in cheek>Hello I am Brown, one of the helicopter emergency service doctors, I do like this orange jumpsuit .... anyway, moving on </tongue in cheek>... this is John, he's 9 years old, running across the kitchen floor, slipped in some water, gone backward and landed hard on his back. Complains of extreme 10/10 right flank and pelvic pain laterally radiating inward and superior but no neck or head pain and denies any LOC. No obvious fractures, no crepitus, only pain upon palpation, physiologically quite stable and given him 2mg of morphine, pain has gone down to 3/10."