The Most Important Question - Trauma Edition

Last week I posted about the most important question to continually ask yourself while working through a call: “What else is going on with this patient? What else could it be?” Repeatedly working through other possibilities on your differential diagnosis list helps you to figure out what is actually going on with this specific patient. Use your history taking skills, along with physical exam to exclude possibilities (as much as we can). If you can’t eliminate a diagnosis, you need to strongly consider treating for it. But that was for a medical call.

When on a medical call, it is important for a medic to think through a list of diagnoses that could potentially result in the patient's complaints and overall presentation. A trauma call is slightly different. The main question to repeatedly ask yourself changes from searching for other causes of the presentation to “What else could be damaged?” In addition, where a medical call is run around the history in conjunction with the physical exam, the physical exam becomes much more important in a trauma call. 

Not an injury pattern often seen nowadays: Sword trauma to a skull. I'm sure there was a laceration, too.
What else could be damaged? (Apparently dude got his teeth knocked out too...)

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Picture yourself arriving to a shooting scene. To simplify our scenario, let’s say you’re the second bus on a multiple-victim scene. Your patient is all packaged and ready. He is a 22-year-old male presenting with a gunshot wound to the midline superior abdomen. 

What could be damaged?

A short list includes liver, diaphragm, stomach, small intestine, large intestine, spleen, kidney, gall bladder, pancreas, bladder, lungs, heart, great vessels, spine, and pelvis. Essentially anything in dude’s torso could be damaged as the result of a bullet passing through, right? You don’t know the path of the round, and you certainly don’t know its internal path. This is an easy scenario, with penetrating trauma to the torso. Blunt trauma can result in a much more complex list. Unknown-mechanism trauma and trauma that involves the neurologic system are even worse.

How does one check whether the pancreas was damaged by the bullet? The heart? Great vessels? Liver?

In the case study above, let’s start with the liver, because it is pretty probable to be injured in an epigastric GSW. What are the main results we would expect if the liver had a chunk of high-speed lead pass through it at about 1,000 feet per second? Pain and bleeding, for the most part. Check abdominal tenderness. Is there radiated tenderness away from the gunshot wound? Are there signs of internal bleeding, like Cullen’s sign or Grey-Turner’s sign? What’s the patient’s pressure and heart rate?

How about the lungs? How are the patient’s breath sounds? What is his respiratory rate? Is he dyspneic? Does he feel like he is getting enough air? Is there chest pain away from the wound?

Asking yourself “What else could be damaged?” is what allows you to find the lumbar compression fractures in a patient who fell and landed feet first. Asking that question allows you to find other wounds besides the obvious ones. Searching out other injury patterns takes you past the "distracting injury" to other injuries that are harder to find.* Asking that question is what allows you to broadly use the trauma mechanism to guide your patient care. It is what makes it harder for a change in status to surprise you.

I bet you already correlate mechanism of injury to physical exam - think about how you focus your exam when you find a starred windshield. You already do this - you see the windshield and essentially think to yourself: "What else could be hurt?"

Realize that we don’t have ultrasounds, CT scanners, or x-ray capabilities. All we have is our hands, ears, and eyes. (Tongues and noses too, but let’s not go there…) That is what makes the physical exam so crucial to prehospital success. Use your hands, ears, and eyes to search out anything else that could be hurt.

Medical calls are a search through possible differential diagnoses. Trauma calls are a search through possible organ system injuries. It is slightly different, but the same general idea. In both cases, a great paramedic goes beyond the page in his or her protocol manual titled "Penetrating Trauma" or "Chest Pain" to actually think through the pathology of the specific call.



*Understanding, of course, that the concept of distracting injuries is a questionable one. See, for example, Konstantinidis et al. or Rose et al. for studies that find no distracting injuries in the face of cervical injury.