Trauma orientation manual

Participate in bedside procedures 

If the rest of the team is in the OR, work with the Red APP to ensure that the patient care continues to progress for the remainder of the service.  

The Blue attending is the backup attending during the day, and the ICU attending is the backup at night. If a patient has a change in status (new tachycardia, arrhythmia, hypotension, hypoxia, altered mental status, hemorrhage, sepsis, etc), and the rest of the team is in the operating room, it is your responsibility to alert the backup attending immediately. 

If you have a question regarding the existing plan of care that cannot be answered by the Red APP, go to the operating room to ask for help.  

Assist with notes and order on activations 

Help facilitate communication with therapy, case management, and social work 

Assist with discharges. 

Be familiar with all patients on the service, and should hold the pager/PerfectServe and continue to advance care on the entire service when all residents are scrubbed or in education.  

Concise, focused (not rounds), discuss unstable patients in detail 

Entire sign out should take less than 20 minutes 

Laboratory results/trends 

Pull up daily imaging and other data 

Enter orders in real time 

Resident or APP presenting the patient should not be the person entering orders at the computer 

Do tertiary exams – should occur as close to 24 hours after admission as possible  

Do bedside procedures and operations (trauma floor residents operate on trauma ICU patients) 

Review new patients 

Swift and focused updates on stable existing patients 

Address questions from RNs, RTs 

New plans for unstable or deteriorating patient 

APP coverage Tuesday-Thursday 

Resident coverage Friday-Monday  

Attend trauma activations  

Complete items to assist day team: 

Tertiary exams 

Populate the problem list, update the patient list through the Problem List tab 

Review all orders, cancel duplicate orders 

Prior to patient arrival: Participate in the PreBrief (see poster on wall), introduce yourself and your position, preassign roles, ensure equipment is ready and available 

Patient arrives: EMS providers give 30 second overview/report, during which there should be no talking 

Pt moved to trauma bay bed: ABCDEs with closed loop communication and log roll with C spine precautions (for blunt trauma) 

ER tech places pulse ox, then obtains first BP, then EKG monitor, then temperature 

IVs placed, blood obtained 

CXR for all blunt trauma patients, PXR for pts with unstable pelvis or pelvic pain (discuss with attending), FAST for blunt unstable or penetrating wounds to cardiac box.   

Penetrating trauma patients need early exposure to look for wounds. Wounds should be marked with paper clips, then x-rays should be obtained of all cavities with a wound.  

CXR must be reviewed by senior resident before CT  

Secondary survey then CTs (only when patient is stable) 

Trauma team member must accompany patient to CT 

Follow up FINAL reads on all patients; go to radiology to review scans 

ADD PATIENT TO Epic Trauma list 

Participate in DeBrief (see poster on wall) 

Consult = No trauma activation but seen in the ED.  This includes patient worked by EM first AND transfers from outside that are seen in the ED by trauma. The ED does not see transfers that are “consults.”  

Direct Admit = Transfer from outside that goes directly to an inpatient bed, never seen in ED at any point. 

Any trauma patient with a traumatic injury or physical/social circumstance which requires observation is admitted to Trauma 

Outside hospital transfers:  If you receive a page or call regarding an outside hospital transfer, please refer the caller to the attending on call. All transfers need to be approved by the Attending on call.  

Must be done within 24 hrs. 

AND repeat once the patient can participate (specifically, in head injured or intubated patients) 

Use the tertiary note template.  Include preexisting conditions by clicking on the Tertiary Trauma Quality Improvement button 

Respond quickly and professionally to ALL requests for patient evaluation  

Physically go see the patient in their current location  

Make sure they are added to the Trauma team list 

NO “FYI” or curbside consults and no consults are turned down without attending approval 

Know what you are asking the consultant to do 

Enter an order in the computer AND 

Make verbal contact with MD or APP on consult team 

No consults should be called without discussing with trauma faculty first  

Neurosurgery and ortho have 30 minutes to see the patient  

If IR is consulted for emergent hemorrhage control, they have 60 minutes from the time of consult to sticking the patient. If you have any issues communicating with IR, notify the trauma faculty immediately.  

If the consulting resident is unable to provide a plan regarding severely injured patients in a timely fashion (i.e. whether a patient with a severe TBI will get an ICP monitor or craniectomy, timing for fixation of unstable spine), obtain contact information for the consulting attending, and the trauma faculty will call them.  

Notify faculty before performing any invasive procedure 

After procedure, write a procedure note 

READ your note and make it accurate 

Assign note to attending who oversaw the procedure 

Order and follow up on appropriate post-procedural testing (CXR after bronch or CVC placement). You should not go home after completing a procedure until you review post-procedural imaging.  

Sterile technique is required for all invasive procedures (ie. arterial and CVC lines, chest tubes, suturing). Chest tubes and central lines should be done with full gown, gloves, mask, and drapes, if clinical condition allows. 

Call the receiving team to communicate comprehensive handoff information  

CCS will enter floor orders on ICU patients leaving the ICU for the floor   

Do not transfer patients to the ICU without discussing with attending 

Do NOT use the "Generate Note" button! 

Use the Rounding tab and click on Progress Notes, or  

Use the Admission tab and click H&P Notes, or 

Use the Discharge tab and click Discharge Summary. 

Within first 24 hrs of admission (ideally, at time of trauma tertiary), complete an advanced care planning discussion and assessment with every patient. 

The ACP discussion should be documented in EPIC under the note type “advanced care planning” using the dotphrase .ACSACPINITIALDISCUSSION 

All Category II patients require a family meeting within 72 hrs of admission.  This follow-up ACP discussion should be documented in EPIC using the note type “advanced care planning” using the dotphrase “.ACSACPFOLLOWUP” 

Risk of airway compromise 

High risk rib fracture patient with FRC<1000mL 

Presence of pulmonary co-morbidities  

Blunt myocardial injury with new  

arrythmia 

hemodynamic instability 

cardiac failure 

Unstable spine injury 

Frontal contusions >2cm 

Solid organ/pelvis/abdominal injuries with evidence of active extravasation on CT scan 

Need for q1hr vital signs/neuro-vascular checks/interventions/etc.  

Trauma attending discretion 

Age > 70 

C-spine fractures exclusive of spinous and transverse process fractures (without neurologic injury)  

History of sleep apnea who needs narcotics  

New CPAP/BiPAP requirements 

Trauma attending discretion  

All other trauma patients who do not meet criteria for ICU or SDCC admission