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Trauma and Emergency Surgery

Resident Manual

Division of Acute Care Surgery
Department of Surgery
University of Florida





First Edition, June 2009

Authors

Jason P. Wilson, MD
Tad Kim, MD
Dean J. Yamaguchi, MD
Constance W. Lee, MD
Lawrence Lottenberg, MD, FACS
John H. Armstrong, MD, FACS
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Contributing Faculty

Larry C. Martin, MD, FACS
Darwin N. Ang, MD
Scott B Armen, MD, FACS
Philip A. Efron, MD
John I. Hollenbeck, MD, FACS
David W. Mozingo, MD, FACS
Winston T. Richards, MD, FACS

Director, Trauma and Aeromedical Services

Michele K. Ziglar, RN, MSN






























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Table of Contents

Prologue 5

Trauma rotation objectives 6

Trauma gator guidelines 9

Trauma bay roles and responsibilities 14

Trauma junior guidelines 15
Trauma alerts
Trauma consults
Night junior
AM ICU work rounds
Weekends
Unit intern/resident
Clinic
The List
Trach/Peg List

Trauma intern guidelines 23
Trauma alerts
Night intern
AM work rounds
Daytime priorities

Service-specific conferences 25

Epilogue 28

Appendices
I. Rotation objectives by year-level 29
o PGY-1
o PGY-2
o PGY-3
II. Trauma Alert Criteria 33
III. Injury Grading Scales 34
o Liver
o Spleen
o Kidney
o Pancreas
o Diaphragm
o Chest Wall
o Lung
IV. Glasgow Coma Score Scale 37
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V. Mangled Extremity Score 38
VI. Sample dictations 39
o Percutaneous tracheostomy
o Percutaneous endoscopic gastrostomy
tube placement
VII. Medical student guidelines 41
VIII. Tube thoracostomy (chest tube placement) 44
IX. Trach/PEG from start to finish 48
X. EAST practice guidelines 54
XI. Door Codes 55




































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Prologue

This manual represents a collective resident and faculty effort to enhance your
preparedness for the trauma and emergency surgery rotation. This rotation is brisk and
challenging. In many respects, it is a crucible that accelerates clinical and professional growth.
The manual attempts to capture the multiple roles played by each resident year-level.

The rotation is designed around the six core ACGME competencies, and thus, it is fitting
that the manual begins with the objectives by competency, integrated across the PGY 1, 2, and 4
year-levels. Objectives are separated by year level in the Appendices. Review not only your
level-specific objectives, but the other levels as well, so that you can see the context of the
rotation in your surgical progression.

As you use the manual and experience the rotation, please share your thoughts about
revisions and additions that you would recommend.
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TRE Service Clinical Rotation Objectives
(By competency, across PGY-levels)

Patient care

PGY-1: Demonstrate recognition of shock in the initial assessment of the acutely injured patient.
PGY-2: Demonstrate appropriate primary survey and resuscitation of the acutely injured patient.
PGY-4: Demonstrate appropriate initial evaluation and management of the acutely injured
patient.

PGY-1: Demonstrate appropriate pre- and post-operative management of acutely injured and
acute surgery patients on the inpatient ward.
PGY-2: Demonstrate appropriate evaluation and management skills in the care of service
patients in the surgical intensive care unit and in acute surgical consultation.
PGY-4: Demonstrate appropriate coordination of care, to include use of consultants and
radiological imaging, in the management of trauma and acute surgery patients.

PGY-1: Demonstrate effective, safe performance of techniques to stop hemorrhage, close simple
lacerations, and place gastric and bladder catheters.
PGY-2: Demonstrate effective, safe performance of procedures of resuscitation and of adjunctive
critical care procedures (e.g., tracheostomy, percutaneous gastrostomy tube placement, and
open abdomen dressing change).
PGY-4: Demonstrate appropriate operative management of patients with acute abdominal
disease and traumatic injuries of the neck, torso, and soft tissues, to include operating room
preparation and damage control transition.

Medical knowledge

PGY-1: Articulate essential concepts for the initial assessment and management of acutely
injured patients.
PGY-2: Discuss management concepts for patients with traumatic brain, spinal, chest, and
severe musculoskeletal injuries.
PGY-4: Explain the specific evidence-based management of acute traumatic injuries by organ
system.

PGY-1: Describe the assessment, differential diagnosis, and initial resuscitation of patients with
acute abdominal disease.
PGY-2: Discuss the assessment and management of patients with gastrointestinal hemorrhage,
abdominal catastrophe, and soft tissue infection.
PGY-4: Review the specific assessment and operative management of patients with acute
abdominal disease and gastrointestinal tract hemorrhage.

PGY-1: Discuss the basic science that drives pre-operative and post-operative care, to include
fluids and electrolytes, pain management, and anticipated complications.
PGY-2: Describe the basic science that drives resuscitation and management of the critically
injured and acute surgically ill, to include blood transfusions, nutrition, and prophyl axis.
PGY-4: Review the basic science underlying the management of elderly, pregnant, and
immunocompromised patients with acute traumatic injury and acute surgical disease.

Practice-based learning and improvement

PGY-1: Describe successful management of post-operative problems for specific patients.
PGY-2: Describe evidence regarding management and prevention of specific surgical
complications.
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PGY-4: Analyze trends and opportunities for process improvement by reviewing trauma and
emergency surgery service statistics.

PGY-1: Discuss injury and disease characteristics related to specific ward patients.
PGY-2: Explain evidence-based management of specific critically injured and ill patients in the
surgical intensive care unit.
PGY-4: Review critical steps in the performance of operations in specific patients.

PGY-1: Identify opportunities for care improvement in individual patient cases.
PGY-2: Appraise performance of procedures in trauma resuscitation and the intensive care unit.
PGY-4: Analyze operative execution and outcome in light of the operative plan for specific
patients.

Interpersonal and communication skills

PGY-1: Demonstrate clear and accurate written communication in ward progress notes and
discharge summaries.
PGY-2: Demonstrate clear and accurate written communication in intensive care unit progress
notes and consultations.
PGY-4: Demonstrate clear, concise, and accurate written communication in operative notes.

PGY-1: Demonstrate clear and accurate verbal communication in the care of service ward
patients.
PGY-2: Demonstrate clear, concise, and accurate verbal communication in the care of service
intensive care unit and consultation patients.
PGY-4: Demonstrate clear, concise, accurate, and integrated verbal communication in the care
of trauma and acute surgery patients.

PGY-1: Demonstrates respectful and appropriate communication with patients, families, nurses,
consultants, peers, and faculty.
PGY-2: Demonstrates respectful and purposeful communication with patients, fami lies, nurses,
consultants, peers, faculty, and consulting services.
PGY-4: Demonstrates respectful and purposeful communication with patients, families, nurses,
consultants, peers, faculty, consulting services, and pre-hospital personnel.

Professionalism

PGY-1: Demonstrates equanimity in interactions with patients, families, and all members of the
health care team.
PGY-2: Demonstrates equanimity in interactions with patients, families, and all members of the
health care team.
PGY-4: Demonstrates equanimity in interactions with patients, families, and all members of the
health care team.

PGY-1: Demonstrates appropriate appearance and affect for specific health care settings.
PGY-2: Demonstrates appropriate appearance and affect for specific health care settings.
PGY-4: Demonstrates appropriate appearance and affect for specific health care settings.

PGY-1: Demonstrates effective time management (punctual, available, tasks completed on time).
PGY-2: Demonstrates effective time management (punctual, available, tasks completed on time).
PGY-4: Demonstrates effective team management.

Systems-based practice

PGY-1: Explain the role of pre-hospital care in supporting evaluation and management of acutely
injured patients.
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PGY-2: Explain the role of a triage system in appropriate disposition of acutely injured patients
to the trauma center.
PGY-4: Distinguish pitfalls in transitions from pre-hospital to hospital care and in inter-facility
transfers for acutely injured and acute surgical patients.

PGY-1: Describe resources available to facilitate the recovery of patients following definitive
management of traumatic injury and acute surgical disease.
PGY-2: Use appropriate outpatient management to promote recovery of patients from traumati c
injury and emergent surgical disease.
PGY-4: Summarize system challenges for patient recovery following traumatic injury and severe
surgical illness.

PGY-1: Discuss behaviors that lead to traumatic injury and acute surgical disease.
PGY-2: Discuss interventions that can reduce the risk of traumatic injury and acute surgical
disease.
PGY-4: Differentiate programs that can reduce the incidence of trauma and acute surgical
disease.




































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Trauma Gator Guidelines

1. The rule: 4 things you must know about every trauma patient (alert or pre-CT scan
consult)
Systolic blood pressure
GCS
Hematocrit
FAST

2. Everyone is bleeding until you prove they are not:
Vital signs
O2 sat
FAST
Exam
Chest x-ray
Pelvis x-ray
Hb/Hct
pH/base deficit
Lactic acid
CT chest/abdomen/pelvis

3. Just do it: residents have the authority to upgrade to Trauma Alerts
BP less than 90 systolic
GCS < 12
Penetrating injury, pelvic fracture, >1 long bone fracture (See Appendix II: Trauma Alert
Criteria)

4. EM attending is in charge of the trauma room until the trauma attending arrives, and then the
process is shared between the two.

5. The room must be silent when RSI intubation is being done; the only two people talking are
the intubating resident and the supervising attending.

6. Draw all blood via vacutainer tubes from the right femoral artery (not vein) after cutting or
removing all clothing. Place the needle directly in the artery and hold pressure for 3 minutes
after removing needle.
A red top tube is immediately given to a nurse to run ISTAT: Hb, Hct, Na, K, Ca, Cr,
ABG, INR, PT, lactic acid.
All other tubes are drawn, but in general only a BAL (EtOH) and Type and Screen is
sent to the lab; BMP, SMA22, amylase, and lipase are patient/disease-specific.

7. Hold pressure with left hand and place lubricant on the right index finger, lift one leg, and do
the rectal. Assess for blood, tone, prostate position, and bone fragments.

8. Place the Foley quickly and clamp the Foley until the FAST is completed.

9. X-rays: Obtain chest and pelvis only (no C-spine x-rays are done; CT is used to clear
cervical spine)

10. Mandatory radiographs on all falls from a height of 6 feet or higher, if mental status precludes
adequate clinical exam
Complete spine CT with reconstruction (cervical, thoracic, lumbar)
Bilateral wrist x-rays
Bilateral ankle (calcaneal) x-rays

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11. Mandatory radiographs on all ejections (from a vehicle, motorcycle, ATV, bicycle, jet ski,
boat)
Complete spine CT with reconstruction (cervical, thoracic, lumbar)

12. For morbidly obese patients in whom adequate clinical exam may be more difficult,
consider extremity radiographs if clinical suspicion warrants, based on mechanism of
injury. This can be done after the patient leaves the trauma room if the patient is in extremis.

13. FAST exam
Enter the patients name and number
Turn the body marker on
Depth should be around 17 for most adults
Every exam is done in this order: subxiphoid RUQ LUQ pelvis RUQ.
A copy of the FAST exam must be in every patients chart, no exceptions.
If the printer is not working, save all images so they can be printed later.

14. Lines (if CVL and/or arterial line is indicated)
Place Arrow 9F soft triple lumen introducer in subclavian vein (if there is a chest tube on
one side, use that side). Avoid putting introducers or CVL lines in the same side as
penetrating chest trauma.
Place 5F 15 cm or 20 cm arterial line in right femoral artery (suture in place with the guide
wire in the lumen, then remove guide wire and hook to monitor).
Place 9F Cordis stiff introducer for the femoral vein or saphenous vein cutdown.

15. Maintain sharps awareness at all times! If you perform the procedure, you are responsible
for disposing of the sharps. This is a major patient and health care team safety issue.

16. Obtain CT cystograms (dye instilled into the bladder during CT) on all patients with pelvic
fractures and hematuria.

17. Be wary of open book pelvic fractures and apply pelvic binder to reduce pelvic volume.
Measure the diastasis on pelvic radiograph before and after placement of the pelvic binder

18. All trauma patients (consults or alerts) needing admission are admitted to the Trauma Service
for at least the first 24 hours.

19. Patients who should have both an introducer and an arterial line include:
Patients in shock
Patients with severe pelvic fractures or multiple extremity fractures

20. Be cautious with these injuries/characteristics:
Dislocated hip fractures needing reduction with multiple injuries
Multiple extremity fractures requiring reduction and splinting/traction
Elderly multiply injured

21. Call the ICU Fellow at 494-9189 ASAP when it is determined the patient needs ICU care.

22. After initial volume resuscitation, reassess the patient based on resuscitation endpoints:
mentation, exam, hemodynamics (BP, HR, CVP), urinary output, labs (Hgb/Hct, base deficit,
lactate, pH, SvO
2
). Categorize the patient as responder, transient responder, and non-
responder.

23. Seven sources of significant hidden hemorrhage
Chest
Abdomen
Pelvic
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Long-bone fractures
Scalp laceration
Oral/maxillofacial (swallowed)
Blood left at the scene

24. If the patient remains unstable, the most likely source of hemorrhage remains the abdomen.
Rule out abdominal source with repeat FAST or diagnostic peritoneal lavage (DPL) in select
cases.

25. Remember to log-roll the patient prior to leaving the trauma bay; if you do not logroll, you
miss half of the patients body surface!

26. Only call Ortho emergently from the trauma room for dislocations (hip, elbow, or knee) and
mangled extremities; otherwise, wait until plain films and/or CT scans are completed.

27. Only call Neurosurgery emergently from the trauma room for focal neurologic signs, such as
blown pupil, paralysis, or GCS < 8; otherwise, wait until CT scans are completed.

28. All bleeding scalp lacerations should be sutured with running sutures or stapled by trauma or
EM; do not call Plastics, OMFS or ENT emergently to the trauma room for these.

29. Scalp lacerations must be sutured with large (zero, 1-0 or 2-0) nylon or prolene running
suture or stapled, rapidly. All scalp wounds should be wrapped with Kerlex around the head
and around the chin, and then ace- wrapped around the chin. The ace wrap should be
removed in 30 minutes.

30. Leave the bottom of the fourth page of the H&P blank for the attending, and do not sign the
bottom of the fourth page.

31. No patients admitted to the Adult Trauma Service (16 or older) should go to the Pediatric ICU
under any circumstances. If this is going to happen, make the attending aware.

32. DVT prophylaxis
Lovenox prophylaxis is 30 mg sc b.i.d.
Heparin prophylaxis is 5000 sc t.i.d. (CNShead and spinal cord injury).

33. IVC filters
Consult vascular surgery or Dr. Scott Armen for placement of IVC filters.
ORMC guidelines for prophylactic IVC filter placement. Prophylactic IVC filters should
be placed in the following high-risk patients with contraindications to anticoagulation.
(http://www.surgicalcriticalcare.net/Guidelines/IVC_filter.pdf)
o Age > 55 years with isolated long bone fractures
o Severe head injury with coma
o Spinal cord injury with paraplegia or quadriplegia
o 2 long bone fractures with pelvic fracture
o 4 long bone fractures
o Penetrating pelvic venous injury
Without DVT: give prophylactic Lovenox until patient is fully ambulatory
With DVT: give therapeutic Lovenox and then coumadin for six months

34. Antibiotics
Ventilator-associated pneumonia (VAP): 8 days IV
o Start vancomycin and Cefepime.
o Stop vancomycin after 3 days or when culture is not MRSA.
o Stop cefepime if culture is MRSA and continue vancomycin.
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o Consider double coverage for Acinetobacter or Pseudomonas, with extended
course (10-14 days)
Blood culture positive sepsis: 14 days IV
Catheter positive: remove the central line
Hospital-acquired pneumonia (HAP): 10 days IV or PO
Urinary tract infection (UTI): 7 days IV or PO
Wound prophylaxis (administer within one hour and discontinue within 24 hours)
o Class I: Kefzol
o Class II: Cefotan
Open fractures: Kefzol + gentamicin

35. Operating Room
When booking a trauma case in the OR, you must post the case by calling the Charge
Nurse at 494-4890 and the Anesthesia Attending at 494-4990. You must state: I
have a trauma case that needs to go to the trauma room and give the specifics
of the case. If you do not tell the charge nurse the case needs to go to the trauma
room, it may get put in a room with no equipment in it. Tell the OR if orthopedics,
neurosurgery, or facial trauma is going to work with the trauma team. Give the OR the
patients disposition: direct to OR immediately, CT scan first, or ICU first.
Prep the patient from the chin to the mid-thighs, down to the table laterally and with a
groin towel. Prep right over groin lines.
All EKG leads must be on the back.
Have the cell saver ready on all chest or abdominal cases; harvest the blood whether
or not there is a bowel injury. The individual trauma attending can decide whether to
use the harvested blood.
Consider placement of a Sandoz nasojejunal tube on abdominal cases, based on
anticipated need for nutritional support and patient stability. It is highly recommended to
fully Kocherize the duodenum to aid in placement. Suture the tube to the center of the
nose. Run D10W in the jejunal port at 10cc/hr immediately upon arrival in the ICU or
PACU.
Obtain two radiographs of the abdomen to look for retained laparotomy pads or
instruments on every trauma case (except damage control open abdomen), one from
the nipples to the umbilicus and another from the umbilicus to the bottom of the pelvis.
The entire peritoneal cavity must be covered.
Obtain chest radiographs on all thoracotomies or sternotomies (except damage control
open chests) to look for retained laparotomy sponges or instruments.
For post-splenectomy patients who are non-ICU bound and stable, order vaccines to
be administered on post-operative day 5 in the immediate postoperative orders. For
post-splenectomy patients who are ICU bound, order vaccines to be administered on
post-operative day 14 (or on transfer to the floor, whichever is sooner).

o Pneumococcal vaccine:
For adults and in fully immunized children 2 years of age, administer
the 23-valent pneumococcal polysaccharide vaccine (PPV23)
For incompletely immunized children 2 to 5 years of age, and previously
unimmunized children 5 to 9 years of age, administer the 7-valent
conjugate pneumococcal vaccine (PCV7)

o Haemophilus B conjugate vaccine
Administer the Haemophilus influenza type B conjugate vaccine

o Meningococcal vaccine
For patients 2 to 55 years of age, administer the meningococcal
conjugate vaccine (MCV-4)
For patients 55 years of age, administer the meningococcal
polysaccharide vaccine (MPSV-4)
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36. Respect the listkeep it updated. The list is an essential tool for patient safety and care
continuity.

37. You have not spoken to the TRAUMA ATTENDING until you have personally spoken with
him/her either by cell, home, or land-line phone.

38. 80 hours/week means 80 hours/week.

39. Call your TRE attending with any questionsan attending is available to you, 24 hours/day,
365 days/year.









































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Trauma Bay Roles and Responsibilities
RRT
CC Tech
Sr. Resident
Jr.
Resident
EM Resident
Medical Student/
PA
(H&P/Orders)
Nurse 2
(Scribe)
Attending
Trauma & ED
Sr. Resident
PGY5/PGY4/PGY3
FAST
Introducer-Subclavian
A-line-Femoral Artery
EM Attending/EM Resident
Airway- edentulate, tongue, RSI
Breathing- end tidal CO
2
, ambu, NG/OG
Pupils, TMs
Suturing scalp lac (no staples)
Nurse 1
Change field IVs to warm IVs, Second IV, Manual B/P
Vital signs including core temp., Warming measures
Attaches monitors: B/P, pulse oximetry,
EKG electrodes, End tidal CO
2
Monitors & reports physiologic parameters
Assists with procedures as appropriate
Prepares patient for transport
Obtains equipment, supplies, medications
X-Rays
CXR, Pelvis
JR Resident
Vacutainer
Femoral Artery
ABGs
Lactic Acid
Hgb/Hct
BMP/PT/PTT-
Elderly, CHI &
Anticoagulants
BA- all drivers
ETOH suspicion
Rectal Exam
Foley Catheter
Nurse 2 (Scribe)
Documentation on Trauma Flow Sheet
Ensures overall coordination of room
Completes lab slips, applies patient
bracelet, places phone calls for: orders,
diagnostics, admission
Radiology
Tech
RRT
Airway adjuncts
Suctioning
End tidal CO
2
Ambu
FAST
Nurse 1
CC Tech
Attaches monitors:
B/P, pulse oximetry,
EKG electrodes, End
tidal CO2
Performs CPR
Assists with
procedure set-ups
Obtains equipment
and supplies
Charge Nurse
Assists with coordination
of patient care
i-STAT
11/09/07, 03/01/08

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Trauma Junior (PGY-2) Guidelines

1. Trauma alerts

a. Preparation
i. Make sure the room is ready when you arrive.
ii. Make sure that the ultrasound has the correct trauma patient and MR
number, paper and gel.
iii. Make sure that the I-stat kit is ready for the intern.
iv. Make sure printer paper is loaded in the ultrasound machine.

b. When the patient arrives, your role is to evaluate and manage the chest, abdomen,
and pelvis, yet in the context of the primary survey (ABCDE).
A: Airway. C-spine immobilization. Ensure airway patency and assess need for
airway protection or ventilation. (ER resident at the head)
B: Breathing and ventilation. Examine the neck and chest. Injuries that should be
identified in the primary survey are: tension pneumothorax, flail chest with pulmonary
contusion, massive hemothorax, and open pneumothorax.
C: Circulation with hemorrhage control. Assess hemodynamic status Identify and
control obvious external bleeding. Establish IV access and/or central access if
necessary, then begin fluid resuscitation. Examine the abdomen, pelvis, and perform
the FAST exam (adjunct to primary survey) to identify potential sources of internal
bleeding.
D: Disability. Assess level of consciousness, GCS, pupils.
E: Exposure/environment control. Undress patient and keep patient warm.
i. As the trauma junior, you will be evaluating the chest, abdomen, and pelvis.
ii. Perform the FAST after the blood draw and before radiographs.
iii. Make sure the lights are down and that you place the pictograph marker
appropriately.

c. After ABCDE is Resuscitation. Treat/manage/reverse immediately life-threatening
injuries identified in the primary survey.

d. If the intern misses the groin stick after two attempts, then you should draw the blood
as a way to teach the intern how to do the groin stick correctly and efficiently.

e. If central access is required, place a subclavian line (i.e. CVP monitoring, additional
line necessary for resuscitation, or large bore peripheral lines cannot be placed). **
All surgery residents need to complete the CVL training module prior to placing a
CVL **

i. Perform in complete sterile fashion with full universal precautions and sterile
field (e.g., big drape). This can be done even in high stress situations and
has been shown to reduce the risk of catheter-related infections. In the
trauma room, there is a kit that contains sterile gown, sterile sheet, Biopatch,
and Tegaderm.
ii. Review the NEJM video on subclavian vein central line placement
(www.nejm.org).

f. Adequate line/tube fixation is an essential part of every tube/line/drain procedure.
The standard is three-point fixation. Tie the suture first to the skin, and then wrap the
suture limbs around the tube/line/drain before applying the knot. Avoid the U-stitch,
as this may cause underlying soft tissue ischemia.

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g. You may perform or assist the intern with arterial line placement. Arterial lines are
indicated in patients with need for close blood pressure monitoring (i.e. hemodynamic
instability, vasoactive agents) or frequent blood gas or blood sampling requirement.
The preferred site is the right femoral artery, and a 5 Fr, 15 cm long catheter is used.
Arterial punctures are made at an acute angle, not at 90
o
(not perpendicular), and are
not dilated. The sequence is stick, arterial flow, wire, catheter, stitch (before pulling
out the wire), pull the wire out, connect to the transducer, confirm arterial tracing,
dress, and tape the tubing to the patient. Verify that the transducer is zeroed. Often
a repeat I-stat is sent to monitor resuscitation at this point.

h. CT imaging with contrast is preferred through a peripheral IV that has lower flow
rates relative to a central line. Peripheral IV access occasionally is difficult, and thus,
central access may be required. Historically, the radiology techs have been reluctant
to proceed with an intravenous contrast CT scan using a central line. However, the
trauma service has arranged with radiology to permit this when there is not another
viable IV. Peripheral IVs should not be placed in the foot.

i. If the patient has a history of allergic or anaphylactic/anaphylactoid reaction to
contrast, try to avoid a contrasted CT scan. If contrasted CT scan evaluation is
absolutely necessary, use low osmolarity (i.e. Visipaque) and minimum possible dose
to complete the scan. Data have not clearly demonstrated benefit with pre-
medication (with cortisteroids + antihistamine).

j. Remember that intravenous contrast is not benign, and our trauma population
includes chronically ill and elderly patients with renal insufficiency. Obtain an I-stat
creatinine level on patients with any history of renal insufficiency and those with age
> 55. Administer Mucomyst, 1200 mg IV, in the trauma bay before CT scan, for
patients with renal insufficiency or age > 55.

k. Patient disposition after CT scanning depends on findings. The intern should
accompany patients to the ward, and the junior and/or chief should accompany the
patient to the SICU or OR. The junior or chief resident obtains the CT scan readings.
During the day, this requires two visits, one with body-CT and the other with Neuro-
CT (for head and neck). Make sure that you communicate up (chief, attending) and
down (intern, physician extenders) the chain about the radiological readings so that
situational awareness is maintained and appropriate consults are obtained.

2. Consults

a. Respond expeditiously: log in your time of consult, perform the consult (see and
evaluate the patient), report to your chief and/or attending, dictate the consult or
admission H&P, write the orders, and complete the bed request.

b. With a trauma consult, the question to be answered is, Does the patient need to be
admitted? More often than not, the answer is yes. Do not banter with the consulting
emergency physician about the validity of the consult.

c. Every trauma consult should have the four key pieces of data (GCS, Hct, SBP,
FAST) and identified injuries (clinical and radiological). Make sure that ETOH level
and urine drug screen results are recorded as well. Each of these items should be
included on the patient list, and the ER should provide them when they call for a
consult. Patient disposition must be part of the plan.

d. In your rapid assessment, determine if the patient is really a trauma alert disguised
as a consult. You have the ability to upgrade any trauma to a trauma alert. Be
particularly cautious under these circumstances:
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i. ER to ER transfer
ii. Open book pelvic fracturethere can a large amount of initially subclinical
blood loss. Patients with open book pelvic fracture need to have an
introducer, pelvic binder, and arterial line. Converting to a trauma alert
brings resources that move care quickly; otherwise, you are recruiting help
piecemeal with an active circulation issue, which places the patient at risk.

e. Hospital-to-hospital transferred trauma patients may come with outside films and
readings. We cannot rely on outside readings without films, and often, the outside
CT scans have not been performed to trauma criteria. Thus, inadequate scans
should be repeated. Outside torso CT scans may be reviewed (with dictation) by a
radiologist on a case-by-case basis. Scans done within the Shands system (SUF,
AGH, Lake Shore, Stark) will all have images and official dictations within the Shands
computer system (remember to look up by name, not SUF medical record number,
for non-SUF images) and are sufficient (but it is a good idea to review the films with
the UF radiologists).

f. By definition, a consult is a communication between two physicians; thus, each
consult should include an opening statement, Asked by Dr. X [consulting physician]
to evaluate patient for Y [general purposeabdominal pain, traumatic injury, etc].
The top of every consult should state requesting attending, service (e.g., Green or
Orange medicine or ER), and reason for consultation. Make sure that there is
adequate space for the attendings to write a note on the consult. Attendings should
be notified of any procedures to be performed, so that they can ensure appropriate
supervision; these include bedside/ER incision and drainage, chest tube insertion,
and central line placement.
g. Consult responsibilities may be shared with anesthesia and emergency medicine
residents on the service. Although less than ideal, it is acceptable to have the night
float intern see consults during times of overwhelming workload. That being said, no
matter who sees the consult (attending, chief, intern), you are responsible for
knowing all consult patients and you are responsible for having the data. On rounds
in the morning, you may be the only initial continuity between night and day.

h. Hand-offs between care settings are particularly vulnerable points in patient care.
When you admit someone from the ER to the floor, call the night float intern for
patients on the service lines and the trauma intern for TRE to give a report and
review the pertinent issues. Same goes for transfers of ICU patients to 10-5 or IMC
to 10-5.

i. Intraoperative consults require a rapid disposition. Be sure to notify your chief
resident and attending as soon as possible. Approach these consults by determining
what the operating service wants from the consult; whether the problem is medical
(intraoperative judgment), intellectual (experiential knowledge), technical
(approaches), or social (turf awareness); and whether the preoperative diagnosis is
still correct.

3. Night junior (and preparation for the morning)

a. A key principle to surviving the night is get everything done for the morning ASAP
before the flood of consult/trauma alert patients arrives. Unlike life on other services,
the night on TRE is simply a continuation of the day, and work should continue as if it
were day time.

b. Work to get done includes:
i. All check-boxes: Follow-up studies, post-op checks, pre-ops, and
procedures.
18 |G a t o r T r a u m a M a n u a l

ii. Template notes: print out and start writing all of your template notes for the
next morning. Blank templates are kept in the overhead shelf in ICU POD 3.
Fill in date (for next day), time, HD#, POD# and the surgery, most recent
DVT study, IVC Filter, antibiotics/other meds like DVT/GI prophylaxis, and
cultures. You can even fill in the assessment and plan section if you already
know (which you should). For billing and documentation purposes, it is
important to list the relevant/current diagnoses in the assessment section;
avoid making the A/P section just a plan.
iii. The list: Update the list with most recent cultures, pre-albumin, antibiotics
with start/stop dates, and recent DVT study.
iv. Unit/IMC rounds: Round at least twice throughout the night, and write a short
note entitled TRE late/night check to document patient issues (you should
also use this time to simultaneously fill in your AM note templates). Perform
a chart check to see what the day consultants recommended, including
PT/OT and rehab.

c. Anticipated morning transfers: Write transfer orders for patients who you know or
believe will be transferred. Fold them over so the nurses do not prematurely activate
them

d. Anticipated next day OR: Verify pre-operative preparation/pre-op note and write in
advance any post-op orders for patients going to the OR.

e. Daybreak: at 4:30AM, update room numbers and print a working list. Start filling in
the list and notes with labs, and otherwise update the list. Confirm the status of
weekly DVT screening exams and order as appropriate.

f. Know where your students are at night. If they are not attached to you by the hip,
know where they are and get their pager numbers. Make sure a student scrubs on
each and every case. Have them with you on ER work-ups and admissions so they
learn what an acute abdomen looks like. These students will eventually be residents
in the ER or on medicine and it is important that they know as much as possible so
that when they call in the future they will be as educated as possible. It is tough to
teach and be a trauma junior, but the more you do it, the easier and more natural it
becomes. You can also tag-team trauma consult admissions with them (they do the
H&P; you do the exam/orders).

4. AM ICU work rounds

a. Process:
i. The chief resident reads out the ventilator settings, vitals, ins/outs, and
meds/antibiotics.
ii. The unit junior writes the note.
iii. The day junior writes data on the list.
iv. The night junior and medical student check all wounds, trach sites, G-Tube &
chest tube sites, and chest tube function (amount, leak), and then document
findings under wounds in the note.

b. For every ventilated patient, document PaO
2
and FiO
2
(to calculate P:F ratio). Also
document PEEP setting (changes in PEEP and FiO
2
can alter the P:F ratio in lung-
injured patients) in the note. Use a calculator and match with additional criteria to
diagnose ARDS (p/f <200, inciting event, bilateral pulmonary chest radiograph
infiltrates, PCWP <18) and acute lung injury (p/f <300).

c. Remove tubes as indicated/planned.

19 |G a t o r T r a u m a M a n u a l

d. Remember nutrition: Crucial for 5 days at full feeds, then Pivot 1.5.

e. Place transfer orders to facilitate patient flow through the hospital.

f. Review prophylaxis:
i. Venous thromboembolic (Lovenox, subcutaneous heparin, sequential
compression devices, IVC filter)
ii. Stress ulcer (on patients who will be NPO or are on the medication at home)
Ranitidine, 150 mg po bid
Prevacid, 30mg po q day or bid

g. Upper GI bleeding
i. Prevacid, 30mg IV bid
ii. Change to Prevacid, 10mg IV bolus + 6mg/hr gtt if UGI bleeding & Hct drop

h. Be sure to write PT/OT/rehab consults on Mondays and Fridays.

5. Weekends

a. Saturday is a challenging seam in the management of the trauma service because
the on-call resident (and sometimes attending) complement is cross-covering and not
primarily assigned to the service.

b. You should round on the floor with the intern. One of the trauma chiefs does round
until 9 AM, and then you are the senior resident who knows the service. It is best to
complete rounds before the attending arrives in order to find and address any fires
before learning about them with an attending. if you have the time, take ownership
and be the acting trauma chief. Run the list with the intern before you depart on
Saturday afternoon and at 6 PM on Sunday as is done during the week.

c. Communication is key: it is particularly vital in the world of shift work and 80-hour
work weeks. This means that there should be communication when you are off as
well. On the weekends, the juniors should talk to each other. Phone calls should be
made so that the other junior knows the plan. For example if the night person may
be off from Friday morning to Sunday morning, the other junior should call the night
junior to discuss the patients so that both know the plan.

6. Unit intern/resident

a. The unit intern or resident is a great resource. Having been the junior many times
without one, it is much nicer to have one. Know that you are responsible for what
they do, so run the list several times. You and the unit resident should stay in
frequent communication. There is a range of experience across the unit residents
some have never taken care of an inpatient outside of the OR or ER. It is a good
idea to review their orders at first, e.g., fentanyl/propofol/versed drips written for the
floor are less than ideal). Teach them to take out chest tubes, perform wound
assessments, and change VAC dressings.

b. When you are overloaded with consults, have them see the consults. The ER
residents in particular should help see consults and act as the junior resident on
service. Teach them the head-to-toe work-up and write-up of H&P/orders for a
trauma consult. Teach them the work-up of general surgery consults, especially
acute abdomen.

c. At a minimum, the unit intern/resident should be focused on the unit and doing unit
things (f/u cultures, radiographs, tertiary surveys, antibiotics, nutritional parameters,
20 |G a t o r T r a u m a M a n u a l

etc). Just make sure you know what they know because when check out comes at 6
PM or at sit down rounds, you are responsible for what they know, did, or didnt do.

7. Clinic

a. Clinic is on Tuesday mornings and scheduled from 9 AM to 11 AM. It realistically
goes until noon. It is not really that different from when done as an intern, but more is
expected of you. As the junior, you will often be asked to see patients by yourself,
with the students, and with the interns and ARNPs as necessary, all the while
answering pages.
b. There are 22 booked patients and, theoretically, 8 slots for overbooking so that you
have 30 patients booked per week. Especially during times when clinic is manned by
just 3 people (junior, PA/ARNP, and medical student), the key to finishing before
11:30AM is non-stop efficiency and speed.

c. The patients who are following up after discharge, have NO general surgery/trauma
issues, and present for either suture/staple removal, wound check, or just for non-
operative trauma follow-up, should literally should have focused, brief visits. Medical
students can help knock these out fast; just make sure they write a note that you can
use for dictation. Get these done fast, so that you are ahead of the game when you
face either a pre-op or a complex patient.

d. All pre-ops need to be seen by an attending before being booked. Booking a
patient involves a full H&P, consent for operation and blood products, OR scheduling
sheet (includes check-boxes for pre-op labs, imaging, CXR), radiology form for
special imaging (i.e. for barium/ostomy enema before ostomy takedowns), and
updating the Trauma OR scheduling book (to be done by junior or chief, under the
planned date with patient name, procedure, # of hours anticipated, and check boxes
with what is done, like H&P/consent, and what is pending, like a barium enema).
Pre-op efficiency is enhanced by filling out the consent (blood and operative) and
H&P template before walking in the room and following this sequence: go into the
room, do your H&P, get the consent, ask the patient for dates that will/wont work for
OR, staff the patient with the attending, fill out the scheduling & imaging ordering
sheet (if applicable), pencil the patient and operation in the Trauma OR schedule
book, and book the case with the scheduler.

e. All H&Ps and clinic notes are dictated. In general, it is advisable to dictate the clinic
notes at the end of clinic. If you saw the patient with an attending, be sure to dictate
that Dr. X saw and evaluated the patient.

f. Papers regarding insurance and disability are dispositioned through the physician
extenders.

g. If there is a trauma alert during clinic, it is up to the attending du jour and the chief to
determine who goes to the alert and who keeps plowing through clinic. If you get a
consult while in clinic, use your clinical judgment and the judgment of those in clinic
with you (attending, chief) regarding whether it can wait until after clinic (trach/peg) or
if it should be seen now (free air).

8. The List

a. The list is the essential tracking tool for patient care on the service. Each patient is
listed with an acute care surgery attending. If the first-call attending is not an acute
care surgery attending, then list the backup attending. Along the same lines, when
doing bed requests for Trauma Alerts, the admitting attending should always be an
acute care surgery attending.
21 |G a t o r T r a u m a M a n u a l


b. Under diagnosis, only put the actual diagnoses and be specific. For example, if the
patient has facial fractures, list what they are (there is a big difference between an
orbital blow out fracture or a LeForte II fracture, and a non-displaced nasal septal
fracture). The mechanism (i.e., MVC, fall, GSW, etc) goes in the text box.

c. In the text box, please write the age, mechanism of injury, and the critical four (GCS
field/ER, SBP, Hct, FAST). As applicable, include EtOH and urine drug screen
results. Next, document the CTs ordered (h/cs/c/a/p as above if they got a pan
scan) and key events (e.g, if the patient was intubated enroute, in the ER, or in
SICU). After that, list pertinent plans by consult services, most recent negative DVT,
most recent prealbumin, the date they had an IVC filter, and pertinent culture-
antibiotic data.

d. Get into the habit of sitting down once a day and updating the list with chest x-rays
on the intubated patients, cultures, antibiotics, DVT study results, and prealbumins
(on Monday). Remove outdated material.

e. The list is vital. It really cannot be emphasized enough.


9. Trach/PEG list

a. Tracheostomies and gastrostomies are not benign procedures; they deserve
continuity in follow-up so that emerging issues are found as early as possible and
addressed. Further, our availability for these post-operative patients signals our
commitment to referring services for future such referrals.

b. Make sure each patient that has a trach/peg or an OR-placed
gastrostomy/jejunostomy is on the trach/PEG list and that it gets updated at least
once a week. You should update patient location on the list (either use Navicare or
electronic census). Be careful because HIS rounds report will indicate that patients
remain in rooms long after they have died or been discharged, so it is best to check
in patient demographics and then pull up cases/visits. The trach/PEG list is
frequently full of patients who have either been discharged or died, which is poor
form.

c. Check on these patients at least once a week. If there is no unit resident, then the
night junior should perform the trach/PEG list rounds. If you do have a unit resident,
have that person round on the trach/PEG patients twice a week. A short note should
document the assessment of the trach/G-tube function, site, and security (intact
suture fixation). Make sure that patients with G-tubes have an abdominal binder in
place. Tracheostomy shields are sutured to the skin in four corners with 0-silk, and a
tracheostomy tape is applied around the neck. Gastrostomy tube bolsters are
sutured to the skin in four quadrants, and the tube is then sutured in a gentle loop to
the anterior abdominal wall to prevent tension and unplanned removal, all with 0-silk
sutures. This can be a good task, with direction, for medical students.

d. In general, patients stay on the main list for one night following their trach/PEG, and
then are transferred to the trach/peg list the next morning. Sometimes, we pack the
trach and the packing should be removed on POD#1 before transfer to the trach/PEG
list.

e. PEGs are used immediately, prior rate for 24 hours, then increase to goal. The
same applies for IR G-tubes (on our service). There is a protocol on the computer for
22 |G a t o r T r a u m a M a n u a l

feeding/G-tube management; it includes erythromycin, unless otherwise
contraindicated (prolonged QT), and an abdominal binder.


Trauma Intern (PGY-1) Guidelines

1. Trauma alerts

a. The intern is responsible for the femoral arterial stick, rectal exam, and Foley catheter
placement. Rule out a urethral injury (high-riding prostate on rectal exam or blood at
urethral meatus) prior to placement of the Foley.

b. The intern makes sure that the bed request, CT scan request, H&P, and orders are
donethe medical students are very helpful with these. The bed request goes to the
bed request table across from the trauma bay, and the CT scan request goes to the
ER front desk. Get this in early as radiology will not let you come down to the CT
scanner without paperwork in the computer and faxed by the ER to them.

c. If the patient is stable and you are experienced and comfortable with the femoral
stick, then it is acceptable to teach the medical students how to do this. The general
rule in the trauma bay is that everyone gets two attempts with the groin stick and
lines before someone else takes over. If you are struggling, look to the junior or chief
for help. Remember that the femoral artery runs half way between the pubic bone
and the anterior superior iliac spine and sometimes a blind stick is necessary to
obtain blood. There should be no hesitation. Prep the groin with a Hibiclens swab,
then feel the artery or stick where the artery runs. This should be done at a 90
o

angle. The arterial blood is sent for an arterial blood gas and other trauma labs.
Hold pressure for three minutes with your left hand. With your right hand, do the
rectal exam. Make sure you tell the patient what you are doing. Simply lift one leg
and do the rectal exam.

d. Once the rectal is done and is normal, then you can place the Foley. A simple Foley
should be placed in non-intubated patients. A temperature Foley should be placed in
intubated patients. Only females should place female Foley catheterssometimes,
this means a female nurse in the ED.

e. Once the patient is down in the scanner, the intern should add the patient to the list,
starting with age, name, mechanism, +/- restrained, +/- ejected, LOC, GCS, FAST,
Hct, SBP, EtOH/urine drug screen (if applicable or known), what CT scans and
additional radiographs are being done, intended consults and whether or not they are
aware/were called, and any preliminary readings (indicate as prelim).

f. While in the CT scanner, double check the medical students H&Pmake sure
everything is filled in. Write admission orders (or confirm medical student orders).
Include DVT prophylaxis, GI prophylaxis on patients who will be NPO, pain
medications, stool softeners (for when taking PO), anti-nausea (Zofran) and anti-
itching (Benadryl) medications unless there is a contra-indication. Do not write for
Lovenox or GI prophylaxis on any patient who is admitted for observation and is
expected to go home the next day.

g. Make every attempt to fill in the third page of the trauma history and physical exam
with the reads from the scanner. Head and c-spine reads are preliminary until
reviewed by a neuro-radiologist. Chest/abdomen/pelvis CTs are considered to be
final when read by a resident radiologist.

23 |G a t o r T r a u m a M a n u a l

2. Night intern

a. Similar principle as with the juniors: get all check-boxes done so that you are ready
for anything that may come up.

b. Perform post-op checks, pre-op/consents, and any other check boxes from sign-out.

c. Write a pre-op note that lists the procedure, blood needs/ordered, and antibiotics.
Patients admitted for ostomy take-down will need to have rectal pouch enemas, in
addition to mechanical bowel prep.

d. Tee-up anticipated morning discharges. Fill out the discharge paperwork, home
instructions, and scripts, and then dictate the discharge summary. Anticipation helps
to prevent the service from growing out of control.

e. Round on the floor patients and do chart checks to make verify PT/OT disposition
and any other late consult recommendations.

f. Write your floor template notes for the AM. Much of the note can be filled out (except
for labs and vitals), to include date, time, HD#, POD#, surgery, antibiotics and other
medications, DVT and GI prophylaxis, most recent DVT study, IVC filter, and brief
assessment/plan (which you should know). 3
rd
-year medical students on trauma call
do not fill out our service progress notes.

g. Write post-op orders (and fold them over) for patients going to the OR the next day

h. Once you have everything done, touch base with the junior and offer help. Make
yourself available to the junior either to help with check-boxes or pre-ops, consults, or
better yet, procedures like chest tubes. Start to learn the junior role for next year.

i. By 4:30AM, update room numbers, print out a long list, and fill in vital signs/labs for
list and notes.

3. AM work rounds

a. The purpose of AM rounds is to set proper conditions for patient success and
attending rounds.

b. Verify patient status, do an exam, check incisions, change dressings, and write
orders to begin normalizing patients who are close to discharge. Do not spend too
long with any one patientyou should be able to complete floor rounds in an hour.

c. Both the night and day trauma interns round together, along with a trauma chief and
physician extender. However, if there are cases in the OR, then you might still need
to round alone.

d. Think about disposition and removing IMC status on patients are they progress on
the care pathway.

4. Daytime priorities

a. First, dischargesideally, the night intern will have teed them up for AM discharge.
Get final reads, clear collars, complete tertiary surveyswhatever you need to do to
get that patient out of the hospital. Med students can help with reads & tertiaries.

24 |G a t o r T r a u m a M a n u a l

b. Call consultantswhether for new consults or to obtain follow-up/final
recommendations. For all consults, you must know why the consult is being
requestedwhat is the question to be answered. If you do not know, ask!
i. For all of the consult services (Orthopaedics, ENT, Neurosurgery, OMFS),
the person you want to talk to is the resident or ARNP/PA on the service of
the attending who staffed the initial consult (not person on the call pager).
ii. To track down the relevant resident, see who wrote the morning note. If you
cannot read the signature, get the 6 digit doctor # from the note and give it to
the clerk, who can look up their pager for you.
iii. Alternatively, check for a dictated consult or a note indicating the attending,
and then call the on-call pager to ask who is the resident for Dr. X.
iv. Along similar lines, call the services home floor (50075 for Ortho, 50065 for
Neuro) and ask the clerk or charge nurse who first call is for Dr. X.
v. Do not assign medical students to call consults this is inappropriate.

c. Be sure to write PT/OT and rehab consults as patients arrive on the ward. PT/OT
orders must be renewed post-operatively.

d. Get your procedures done pulling chest tubes, drains, dressing/VAC changes.

e. Tee up any pre-ops for the next day: this includes consent for operation and blood,
posting the case (usually done by junior or chief), pre-op note to verify appropriate
work-up including labs, CXR/EKG, or further work-up if indicated, orders for NPO
after midnight, IVF after midnight, T&S or T&C, labs/coags, and antibiotic on-call to
OR. Use the pre-op note as a checkpoint to
i. Verify SCDs, DVT & GI prophylaxis.
ii. Continue Atenolol, 50 or 100 mg po, or metoprolol, 5-10mg IV on call to OR.
Hold only if HR < 55 or SBP < 100.
Ideally, for outpatients, this should be started in clinic.
iii. Hold any therapeutic Lovenox in AM
iv. Set the insulin regimen for insulin-dependent DM patients.
For patients on intermediate or long-acting, give roughly half of usual
AM dose, less (1/3) if surgery will make pt miss breakfast & lunch,
more (2/3) if only missing breakfast.
For patients on multiple short-acting doses, give roughly 1/3 of their
pre-meal dose.
v. Anticipate perioperative steroid needs (2-3 days) of patients on chronic
steroids or hydrocortisone infusion for more than 2 weeks.
Pulse steroids, hydrocortisone, 100mg IV on call to OR, then 50mg
IV q8h x 1 day, then 50mg IV q12h x 1 day, then 25mg IV q12h x 1
d.
4 mg hydrocortisone = 1 mg prednisone.

f. Do the stat dictation and discharge instructions for patients destined for rehab in the
next day or so.










25 |G a t o r T r a u m a M a n u a l

Service-Specific Conferences

1. Multidisciplinary conference

a. This conference occurs at 0730 on Monday and 0800 on Friday, excluding holidays,
and is designed to bring every resource to bear for the acute care and recovery
disposition of every service patient. It gets everyone playing off the same sheet of
music, and brings accountability to care processes. Participants include the surgical
team, nursing staff, PT, OT, social work, case management, rehabilitation, respiratory
therapy, and dietary.

b. This is not a full ICU presentation. For new patients, present the story: age,
mechanism, LOC, GCS, FAST, Hct, SBP, EtOH/UDS, relevant studies, all identified
injuries (from most to least important), consult (neurosurgery, orthopaedics, facial
trauma, PT/OT) recommendations, and plan. For patients who are well-known, say
the name, age, mechanism, and major injuries/diagnoses, then move to current
issues events overnight, overall neuro, respiratory, hemodynamic status, wounds,
UOP/drain/NG output, relevant labs (Hct, WBC), tube feed status (TF at goal),
consult recommendations and plans. Make sure you know individual service plans
for the patients. Think about long term disposition for each patient.

c. On Mondays only, the night team stays and talks about patients admitted or operated
during the previous 72 hours. Then the day person does the rest. The day person is
responsible for presenting all of the patients on Friday. This is also a good time to
make sure you know every services plan (part of the reason we round early on
Monday) so you can decide if they belong on TRE or would be better served on
another service (orthopaedics, neurosurgery, ENT). The idea is to help our patients
move along the care pathway as expeditiously as possible. Focus on ensuring
smooth transitions between care settings (e.g., ICU to ward, ward to home, ward to
rehab, etc).

d. Ward patient discussion should include return of bowel function (e.g., for bowel
surgeries) and activity level (e.g., pt transferred to chair or walked 100ft with PT and
is ready for discharge).

e. Be prepared to run the list in the TRE conference room (M603, 6
th
floor outside the
trauma offices) on Tuesday (before clinic) and Thursday mornings (after service
M&M). The unit resident should hold the pager while the PGY-2 is in conference on
Tuesdays.

2. Trauma Quality Improvement Conference

a. This occurs on the third Tuesday of each month, from 7 AM to 8:45 AM.

b. It has two components, a trauma service statistical and case review, and an
educational session.

c. All residents and students attend.

3. Acute Care Surgery Morbidity and Mortality Conference

a. This occurs every Thursday from 8 AM to 8:45 AM in M603.

b. Complications are identified prior to the conference, and a list is presented by the day
trauma chief resident. All residents and students attend.
26 |G a t o r T r a u m a M a n u a l


c. The service participates in the Department of Surgery M&M conference on a six-
week cycle. Service statistics are reviewed, and a case is presented by one of the
trauma chief residents.

4. TRE Chief: The Curriculum

a. This is a PGY-4 course with two components, a Tuesday morning, 7 AM7:30 AM,
oral review conference, and an electronic journal club with weekly assignments.

b. The texts are Top Knife and Copes Diagnosis of the Acute Abdomen.

5. Surgery 101, 201, and 401: The service supports full resident participation in these courses
on Friday, Tuesday, and Thursday, respectively, from 7 AM to 8 AM. Clinical responsibilities
are covered within the service during these times.




































27 |G a t o r T r a u m a M a n u a l



Epilogue

Being on trauma is far from a perfect world. People in neighboring counties like to be involved in
traumas all at the same time, so I know that Ive spent the whole night in the ER. I know all of this
is demanding and hard to keep straight. Just do everything with the patient in mindthat is the
most important thing.

Graduating Resident


28 |G a t o r T r a u m a M a n u a l

Appendix I: Rotation Objectives by Year-Level

PGY-1 Objectives

Patient care

PGY-1: Demonstrate recognition of shock in the initial assessment of the acutely injured patient.

PGY-1: Demonstrate appropriate pre- and post-operative management of acutely injured and
acute surgery patients on the inpatient ward.

PGY-1: Demonstrate effective, safe performance of techniques to stop hemorrhage, close simple
lacerations, and place gastric and bladder catheters.

Medical knowledge

PGY-1: Articulate essential concepts for the initial assessment and management of acutely
injured patients.

PGY-1: Describe the assessment, differential diagnosis, and initial resuscitation of patients with
acute abdominal disease.

PGY-1: Discuss the basic science that drives pre-operative and post-operative care, to include
fluids and electrolytes, pain management, and anticipated complications.

Practice-based learning and improvement

PGY-1: Describe successful management of post-operative problems for specific patients.

PGY-1: Discuss injury and disease characteristics related to specific ward patients.

PGY-1: Identify opportunities for care improvement in individual patient cases.

Interpersonal and communication skills

PGY-1: Demonstrate clear and accurate written communication in ward progress notes and
discharge summaries.

PGY-1: Demonstrate clear and accurate verbal communication in the care of service ward
patients.

PGY-1: Demonstrates respectful and appropriate communication with patients, families, nurses,
consultants, peers, and faculty.

Professionalism

PGY-1: Demonstrates equanimity in interactions with patients, families, and all members of the
health care team.

PGY-1: Demonstrates appropriate appearance and affect for specific health care settings.

PGY-1: Demonstrates effective time management (punctual, available, tasks completed on time).



29 |G a t o r T r a u m a M a n u a l

Systems-based practice

PGY-1: Explain the role of pre-hospital care in supporting evaluation and management of acutely
injured patients.

PGY-1: Describe resources available to facilitate the recovery of patients following definitive
management of traumatic injury and acute surgical disease.

PGY-1: Discuss behaviors that lead to traumatic injury and acute surgical disease.















































30 |G a t o r T r a u m a M a n u a l

PGY-2 Objectives

Patient care

PGY-2: Demonstrate appropriate primary survey and resuscitation of the acutely injured patient.

PGY-2: Demonstrate appropriate evaluation and management skills in the care of service
patients in the surgical intensive care unit and in acute surgical consultation.

PGY-2: Demonstrate effective, safe performance of procedures of resuscitation and of adjunctive
critical care procedures (e.g., tracheostomy, percutaneous gastrostomy tube placement, and
open abdomen dressing change).

Medical knowledge

PGY-2: Discuss management concepts for patients with traumatic brain, spinal, chest, and
severe musculoskeletal injuries.
PGY-2: Discuss the assessment and management of patients with gastrointestinal hemorrhage,
abdominal catastrophe, and soft tissue infection.

PGY-2: Describe the basic science that drives resuscitation and management of the critically
injured and acute surgically ill, to include blood transfusions, nutrition, and prophylaxis.

Practice-based learning and improvement

PGY-2: Describe evidence regarding management and prevention of specific surgical
complications.

PGY-2: Explain evidence-based management of specific critically injured and ill patients in the
surgical intensive care unit.

PGY-2: Appraise performance of procedures in trauma resuscitation and the intensive care unit.

Interpersonal and communication skills

PGY-2: Demonstrate clear and accurate written communication in intensive care unit progress
notes and consultations.

PGY-2: Demonstrate clear, concise, and accurate verbal communication in the care of service
intensive care unit and consultation patients.

PGY-2: Demonstrates respectful and purposeful communication with patients, families, nurses,
consultants, peers, faculty, and consulting services.

Professionalism

PGY-2: Demonstrates equanimity in interactions with patients, families, and all members of the
health care team.

PGY-2: Demonstrates appropriate appearance and affect for specific health care settings.

PGY-2: Demonstrates effective time management (punctual, available, tasks completed on time).




31 |G a t o r T r a u m a M a n u a l

Systems-based practice

PGY-2: Explain the role of a triage system in appropriate disposition of acutely injured patients
to the trauma center.

PGY-2: Use appropriate outpatient management to promote recovery of patients from traumatic
injury and emergent surgical disease.

PGY-2: Discuss interventions that can reduce the risk of traumatic injury and acute surgical
disease.














































32 |G a t o r T r a u m a M a n u a l

PGY-4 Objectives

Patient care

PGY-4: Demonstrate appropriate initial evaluation and management of the acutely injured
patient.

PGY-4: Demonstrate appropriate coordination of care, to include use of consultants and
radiological imaging, in the management of trauma and acute surgery patients.

PGY-4: Demonstrate appropriate operative management of patients with acute abdominal
disease and traumatic injuries of the neck, torso, and soft tissues, to include operating room
preparation and damage control transition.

Medical knowledge

PGY-4: Explain the specific evidence-based management of acute traumatic injuries by organ
system.

PGY-4: Review the specific assessment and operative management of patients with acute
abdominal disease and gastrointestinal tract hemorrhage.

PGY-4: Review the basic science underlying the management of elderly, pregnant, and
immunocompromised patients with acute traumatic injury and acute surgical disease.

Practice-based learning and improvement

PGY-4: Analyze trends and opportunities for process improvement by reviewing trauma and
emergency surgery service statistics.

PGY-4: Review critical steps in the performance of operations in specific patients.

PGY-4: Analyze operative execution and outcome in light of the operative plan for specific
patients.

Interpersonal and communication skills

PGY-4: Demonstrate clear, concise, and accurate written communication in operative notes.

PGY-4: Demonstrate clear, concise, accurate, and integrated verbal communication in the care
of trauma and acute surgery patients.

PGY-4: Demonstrates respectful and purposeful communication with patients, families, nurses,
consultants, peers, faculty, consulting services, and pre-hospital personnel.

Professionalism

PGY-4: Demonstrates equanimity in interactions with patients, families, and all members of the
health care team.

PGY-4: Demonstrates appropriate appearance and affect for specific health care settings.

PGY-4: Demonstrates effective team management.



33 |G a t o r T r a u m a M a n u a l

Systems-based practice

PGY-4: Distinguish pitfalls in transitions from pre-hospital to hospital care and in inter-facility
transfers for acutely injured and acute surgical patients.

PGY-4: Summarize system challenges for patient recovery following traumatic injury and severe
surgical illness.

PGY-4: Differentiate programs that can reduce the incidence of trauma and acute surgical
disease.
34 |G a t o r T r a u m a M a n u a l

Appendix II: Trauma Alert Criteria

Adult Criteria (any one of the following)

Active airway assistance more than oxygen
Lack of radial pulse with sustained heart rate greater than 120 or systolic blood pressure
less than 90 mmHg
Best Motor Response of less than or equal to 4 (withdraws from pain) OR
o Paralysis OR
o Suspected spinal cord injury OR
o Loss of sensation
2
nd
or 3
rd
degree burns greater than or equal to 15% TBSA OR
o Amputation proximal to wrist or ankle OR
o Penetrating injuries to the head, neck, or torso (excluding superficial wounds
where the depth of the wound can be determined
2 or more long bone fracture sites (humerus, radius/ulna, femur, or tibia/fibula)
Paramedic discretion

Adult Criteria (any two of the following)

Respiratory rate greater than or equal to 30
Heart rate greater than or equal to 120
Best Motor Response of 5 (localizes pain)
Major degloving injury OR
o Flap avulsion greater than 5 cm OR
o Gunshot wound to the extremities
Single long bone fracture from MVC or fall greater than or equal to 10 feet
Age greater than or equal to 55
Ejection from motor vehicle (excluding motorcycle, ATV, bicycle, or the open body of a
pick-up truck) OR
o Steering wheel deformity

35 |G a t o r T r a u m a M a n u a l

Appendix III: Organ Injury Scales

Liver

Grade Injury Type Description
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm parenchymal depth
II Hematoma Subcapsular, 10-50% surface area;
intraparecnhymal, <10 cm in diameter
Laceration Capsular tear, 1-3 cm parenchymal depth, <10 cm in length
III Hematoma Subcapsular >50% surface area or expanding; ruptured subcapsular
or parenchymal hematoma; intraparenchymal hematoma >10 cm or
expanding
Laceration >3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3
Couinauds segments within a single lobe
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3
Couinauds segments within a single lobe
Vascular Juxtahepatic venous injuries (retrohepatic vena cava/central major
hepatic veins
VI Vascular Hepatic Avulsion
Advance one grade for multiple injuries up to grade III

Spleen

Grade Injury Type Description
I Hematoma Subcapsular <10 % Surface Area
Laceration Capsular tear, <1 cm parenchymal depth
II Hematoma Subcapuslar 10%-50% surface Area;
intraparenchymal < 5 cm in depth
Laceration Capsular tear, 1-3 cm parenchymal depth, which does not involve a
trabecular vessel
III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular
or parenchymal hematoma; intraparenchymal hematoma >5cm or
expanding
Laceration >3 cm parenchymal depth or involving trabecular vessels
IV Laceration Laceration involving segmental or hilar vessels producing major
devascularization (>25% of spleen)
V Laceration Completely shattered spleen
Vascular Hilar vascular injury that devascularizes the spleen
Advance one grade for multiple injuries up to grade III
36 |G a t o r T r a u m a M a n u a l

Kidney

Grade Injury Type Description
I Contusion Microscopic or gross hematuria, urologic studies normal
Hematoma Subcapsular, nonexpanding hematoma without parenchymal
laceration
II Hematoma Nonexpanding perirenal hematoma confined to retroperitoneum
Laceration <1 cm parenchymal depth of renal cortex without urinary extravasation
III Laceration >1 cm parenchymal depth of renal cortex without collecting system
rupture or urinary extravasation
IV Laceration Parenchymal laceration extending through the renal cortex, medulla,
and collecting system
Vascular Main renal artery or vein injury with contained hemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilam, which devascularizes kidney
Advance by one grade for bilateral injuries up to grade III

Pancreas

Grade Injury Type Description
I Hematoma Minor contusion without duct injury
Laceration Superficial laceration without duct injury
II Hematoma Major contusion without duct injury or tissue loss
Laceration Major laceration without duct injury or tissue loss
III Laceration Distal transection or parenchymal injury with duct injury
IV Laceration Proximal transection or parenchymal injury involving ampulla
V Laceration Massive disruption of pancreatic head
Advance by one grade for multiple injuries up to grade III

Diaphragm

Grade Injury Type Description
I Contusion Contusion
II Laceration <2 cm
III Laceration 2-10 cm
IV Laceration >10 cm with tissue loss <25 cm2
V Laceration Tissue loss >25 cm2
Advance one grade for bilateral injuries up to grade III


Chest Wall

Grade Injury Type Description
I Contusion Any Size
Laceration Skin and subcutaneous tissue
Fracture < 3 ribs, closed; nondisplaced clavicle closed
II Lacerations Skin, subcutaneous tissue and muscle; > 3 adjacent ribs closed
Fracture Open or displaced clavicle; Nondisplaced sternum, closed; scapular
body, open or closed
III Laceration Full thickness including pleural penetration; open or displaced
sternum; flail sternum
Fracture Unilateral flail segment (< 3 ribs)
IV Laceration Avulsion of chest wall tissues with underlying rib fractures
Fracture Unilateral flail chest (>3 ribs)
37 |G a t o r T r a u m a M a n u a l

V Fracture Bilateral Flail chest
Advance one grade for bilateral injuries up to grade III

Lung

Grade Injury Type Description
I Contusion Unilateral, <1 lobe
II Contusion Unilateral, single lobe
Laceration Simple pneumothorax
III Contusion Unilateral, >1 lobe
Laceration Persistent (>72 hours) air leak from distal airway
Hematoma Nonexpanding intraparenchymal
IV Laceration Major (segmental or lobar) air leak
Hematoma Expanding intraparenchymal
Vascular Primary branch intrapulmonary vessel disruption
V Vascular Hilar vessel disruption
VI Vascular Total, uncontained transection of pulmonary hilum
Advance by one grade for bilateral injuries up to grade III
Hemothorax is scored under thoracic vascular injury scale































38 |G a t o r T r a u m a M a n u a l

Appendix IV: Glasgow Coma Scale

Eyes GCS score
Opens eyes spontaneously 4
Opens eyes in response to voice 3
Opens eyes in response to painful stimuli 2
Does not open eyes 1

Verbal
Oriented, converses normally 5
Confused, disoriented 4
Utters inappropriate words 3
Incomprehensible sounds 2
Make no sounds 1

Motor
Obeys commands 6
Localizes painful stimuli 5
Flexion/withdrawal to painful stimuli 4
Abnormal flexion to painful stimuli 3
Extension to painful stimuli 2
Makes no movements 1































39 |G a t o r T r a u m a M a n u a l

Appendix V: Mangled Extremity Severity Score (MESS)

Skeletal/soft tissue Injury Score
Low energy (stab; simple fracture; pistol gunshot wound) 1
Medium energy (open or multiple fractures; dislocation) 2
High energy (high speed MVA or rifle GSW) 3
Very high energy (high speed trauma + gross contamination) 4

Limb ischemia
Pulse reduced or absent but perfusion normal 1*
Pulseless; parasthesias, diminished capillary refill 2*
Cool, paralyzed, insensate, numb 3*
*Score doubled for ischemia > 6 hours

Shock
Systolic BP always >90 mmHg 0
Hypotensive transiently 1
Persistent hypotension 2

Age
< 30 0
30-50 1
> 50 2






























40 |G a t o r T r a u m a M a n u a l

Appendix VI: Sample dictations

Percutaneous tracheostomy

The patient remained in the Intensive Care Unit with full hemodynamic and oxygenation
monitoring. After informed consent was obtained from the patients health care surrogate, the
patients head and neck were prepped and draped in sterile fashion. A timeout was called to
confirm patient, site, and operation, as well as the administration of prophylactic antibiotics [class
2 case, review existing antibiotics, which usually cover this aspect] and the application of
functioning Flowtron boots. A level of sedation, analgesia, and chemical paralysis appropriate for
the procedure was confirmed. Local anesthesia (1% lidocaine with epinephrine) was infiltrated
into the soft tissues of the intended incision. The skin incision was made sharply in the midline of
the anterior neck, just cephalad to the jugular notch and inferior to the cricoid cartilage and
continued with electrocautery through the superficial, investing, and pretracheal fascia, to include
the thyroid isthmus. The anterior trachea was clearly visualized, to include the interspace
between tracheal rings two and three.

Critical care medicine colleagues then introduced a bronchoscope into the endotracheal tube,
and the endotracheal tube and bronchoscope were simultaneously withdrawn until the
transluminal light reflex was seen externally and the external indentation between tracheal rings
two and three was clearly visualized endoscopically. A catheter-over-needle was then placed
under direct bronchosopic vision between tracheal rings two and three, and the needle was
removed. A guidewire was placed through the catheter and directed distally under direct
bronchoscopic vision. The catheter was removed, and the tracheotomy was sequentially dilated
using a Blue Rhino kit. A #8 Shiley tracheostomy tube with inner dilator was then passed over
the guidewire and into the tracheal lumen under direct bronchoscopic vision. The guidewire and
dilater were removed, the inner cannula was placed, and the cuff balloon was inflated.
Mechanical ventilation through the tracheostomy confirmed end-tidal CO
2
. Bronchoscopy
through the tracheostomy visualized the carnina. The tracheostomy shield was sutured to the
skin in four corners with 0-silk, and a tracheostomy tape was applied. The estimated blood loss
was 3 cc. No specimens were sent to pathology. The patient remained in the ICU.


Percutaneous Endoscopic Gastrostomy Tube Placement

Following tracheostomy, our attention turned to assessment for suitability of PEG tube
placement. The upper endoscope was introduced through a bite block into the mouth and
directed endoscopically into the esophagus, stomach, and duodenum. The stomach was first
suctioned of contents and then insufflated. The esophageal, gastric, and duodenal mucosa to the
2
nd
portion were normal without evidence of inflammation, ulceration, or mass lesions. The
pylorus and angularis were normal. A retroflexed view of the cardia and fundus was normal. The
stomach was maximally distended via insufflation, and a strong light reflex was visualized in the
left upper quadrant. External indentation at the point of maximum light reflex was visualized
endoscopically. 1% Xylocaine was infiltrated into the skin overlying the intended site, and a stab
wound was made through the skin. A catheter-over-needle was then passed through the stab
wound and into the gastric lumen under direct endoscopic vision. The needle was removed, and
a guidewire was passed through the catheter and into the gastric lumen under direct endoscopic
vision. The guidewire was endosnared and brought out through the mouth with the endoscope.
The gastrostomy tube was then attached to the guidewire and and pulled through the mouth and
out the anterior abdominal wall to the X cm mark. The external bolster was placed.

The upper endoscope was reintroduced through the bite block and into the stomach to confirm
proper button placement without mucosal blanching or laxity, absence of bleeding, and 360
degree mobility of the button. The stomach was suctioned, and the endoscope was withdrawn.
The bolster was secured with 4 simple interrupted 0-silk sutures. The external gastrostomy tube
41 |G a t o r T r a u m a M a n u a l

taper was cut off, and the port adapter was placed. The gastrostomy tube was sutured in a
gentle curve to the anterior abdominal wall with several 0-silk sutures. The estimated blood loss
was 3 cc. No specimens were sent to pathology. The patient remained in the ICU.















































42 |G a t o r T r a u m a M a n u a l

Appendix VII: Trauma Medical Student Guide

1. Trauma alerts
a. In the trauma bay, medical students are responsible for the H&P, bed request, and CT
scan order form. As you become faster, you can also help fill out orders. The intern or
junior resident should double-check and sign the H&P, CT scan request form, and orders
after youve filled them out. All sections should be filled out on the H&P form, and if there
are any assessments missing, call out to the resident to perform the exam you need.
The H&P is structured as a learning tool. On the first page of the H&P form, in a
separate boxed area, write the critical four: GCS, FAST, Hct, and SBP on presentation to
ED.

b. If there is time and the situation is not as urgent, there is a role for medical students to
learn and help with the arterial stick for blood, rectal exam, and Foley (interns role).
Dont get too caught up in the paperwork or miss out, especially if there is an opportunity
for procedure or learning (i.e. were performing an ED thoracotomy). Any patients who
received a femoral arterial line will need to be changed over (in the ICU) to a radial
arterial line as soon as possible. This is an opportunity for you students. Stay with the
patient from the trauma bay until the patient reaches an assigned bed.

c. Start the tertiary exam once the patient reaches that bed. A tertiary exam is a full
H&P/review of studies performed including history/mechanism, social/medical/surgical
history/allergies, a full head-to-toe physical exam checking all bones and joints,
neurologic exam, review of all laboratory trends (especially hematocrit, creatinine) and all
radiology final reads, all consults final recommendations, and plan. If all final reads are
done, then complete the tertiary, have a resident sign it, and place it on the chart. If there
are a few final reads pending still, mark the area that needs a read with a different color
pen or some type of symbol like a star (*) and put it in the box.

2. Consults

a. Especially during nights, a student should be with the junior or consult resident on all
consults or admissions. It is a learning opportunity and part of your rotation objectives to
learn about the presentation, evaluation, and work-up of the acute abdomen. For any
acute abdomen, such as appendicitis or cholecystitis, make sure to perform your own
physical exam.

b. Treat trauma consults exactly as you would a trauma alert. You can help the junior with
the H&P, orders, and bed request.

c. Start the tertiary right away once the patient is admitted.

3. Trauma night call

a. Night call begins at 6 PM on ward 10-5 with hand-off rounds between the day and night
shifts.

b. Student night call involves being present at trauma alerts, for consults and ward
emergencies, and in the operating room. Students not assigned to the trauma service
for their four week rotation are not expected to write trauma service progress
notes.

c. A student should scrub on every case at night. Likewise, a student should be with the
junior resident at all times to learn and assist. Go to all trauma alerts. Help complete any
pending tertiaries or start tertiaries on any trauma admissions.
43 |G a t o r T r a u m a M a n u a l


d. Trauma call is a good opportunity to perform procedures. Earlier in the year, interns will
want to perform laceration repairs and chest tubes to gain experience, but later in the
year, residents are happy to assist you in laceration repair, incision and drainage of
abscesses in the ED or on the medicine floors. When you begin call, let the intern and
junior/chief know that youre interested in learning, helping, or doing procedures. The
more available you make yourself (instead of hiding/sleeping), the more opportunities you
will find and the more opportunities the residents are likely to give you.

4. Multidisciplinary conference

a. Monday conference is at 7:30 AM, and thus, we round at 5:30 AM on Mondays. Friday
conference is at 8 AM.

b. This conference reviews every patient on the service in the setting of all available
resource representatives (surgical team, nurses, PT, OT, dietary, rehab, social work,
case management). The purpose is to facilitate patient progress on the care pathway to
recovery.


5. Daytime

a. A student should scrub in on every OR case and every ICU trach/PEG procedure.
Learning takes priority over paperwork, but the floor work is also an opportunity to learn
and be part of the team.

b. On morning rounds, medical students should enter the room, perform a focused exam of
heart, lungs, abdomen, general neuro status (mental status, extremity movement), and
pulses. Wounds should be inspected in the context of dressing changes, and drain
output should be assessed. orough process can tend to deteriorate into just a wound
check. Another good skill to learn (that really applies more to the interns) is assess what
is still attached to the patient (central lines, IVs, Foley catheters, drains, chest tubes and
NG tubes) and to figure which can be removed/discontinued.

c. It is a good idea to have a pair of scissors in your coat/scrub pocket, extra 4x4 gauze,
and paper tape. At the very least, carry around the scissors and then rely on the
rounding cart for the gauze, tape, Kerlex, etc. Medical students are also responsible for
keeping the cart stocked with gauze, tape, Kerlex, abd pads, and 1L normal saline
bottles. Be sure to clean your scissors after each use.

d. After rounds and conference (on Mon/Fri), help the intern or resident finish basic and
minor procedures before going to the OR (if there is time). This includes pulling drains,
chest tubes, NGT/Foleys (which can also be done on rounds), wound debridements, VAC
dressing changes, laceration repairs, or delayed primary closure of wounds. One thing to
note about drains, our surgical drains (clear, stretchy tubing) can be pulled right out. The
drain you need to be careful of is the pigtail catheter which is usually a blue tubing
these need to be unlocked and the suture/tie cut before pulling the pigtail drain out,
because that suture is what is preserving the pigtail shape inside the body; if the suture is
not cut, the pigtail will shred its way through tissue as youre pulling it out. If you are at all
uncertain about a drain, ask for help.

e. The day should follow this order, from highest to lowest priority:

i. Discharges are first priority. Medical students primary role in helping to move
patients to discharge is completing the tertiary.
44 |G a t o r T r a u m a M a n u a l

ii. Calling consults. Residents should not have you call new consults. It is not
appropriate, and these should be resident-to-resident communication. If the
workload is tremendous, then it may be acceptable to have a student call a
service for a follow-up recommendation. Just make sure that you present like a
resident would dont give them any hint that youre a medical student.
iii. Procedures (mentioned above)
iv. Write pre-op notes for patients going to the OR in the next day or so. This
includes:
Pre-op diagnosis
Planned procedure
Attending surgeon
Pre-op work-up meaning labs especially CBC & Coags, chest x-ray,
EKG, any other work-up for surgery (i.e. barium enema before ostomy
takedown)
Consent on chart
H&P on chart
Physician pre-op orders
a. NPO p MN with IVF
b. Blood products (T&C) or at least a T&S on almost every patient
c. Antibiotic on-call to OR
i. Kefzol 1g for skin
ii. Vancomycin 1g if ceph allergic
iii. Cefotan 1g for colon
iv. Timentin 3.1g for complex bowel/biliary or suspect perf
viscus
v. Cipro 400mg/Flagyl 500mg if pen-allergic for bowels
d. Beta-blockade
i. Atenolol 50 or 100mg po x1 or metoprolol 5-10mg IV on
call to OR
ii. Hold only if HR < 55 or SBP < 100
iii. For outpatients, this should be started in clinic.
e. Diabetics on insulin need adjusted dose (ask the resident)
f. Chronic steroid therapy needs pulse hydrocortisone 100 mg IV
on call to OR and 50 mg IV q8h for the first day post-operatively,
then taper to home dose. 4 mg hydrocortisone = 1 mg
prednisone
v. Do post-op checks on any cases you were scrubbed in


















45 |G a t o r T r a u m a M a n u a l

Appendix VIII: Tube thoracostomy (chest tube placement)

Initial steps

1. Obtain consent for (right or left) tube thoracostomy and all indicated procedures.
2. Have the nurse get a chest tube set-up and Pleuravac set-up at the bedside.
3. Order morphine 2-4mg IV x1 for procedure and have the nurse administer this.
4. If the patient is especially anxious, order Ativan or Versed 0.5mg IV x1 as well.

On 10-5 Trauma

On the trauma ward, there are chest tube set-up packages which include the standard
thoracostomy tray with instruments, as well as Pleuravac, masks, 20 gauge needle, vaseline
gauze, 4x4 gauze, betadine, silk tape, scalpel, & suture.

The only additional items you will need are:
(1) 4x4 gauze tub
(1) lidocaine with(20mL bottle) or without(30mL bottle) epinephrine
(1) 10mL syringe
(1) 25 gauge needle for injecting the skin with lidocaine
(4) sterile towels
(2) small barrier sheets
(2) sterile gowns (if you have an assistant or teacher with you)
(2) hats
(1) bottle of sterile water for the pleuravac
(1) #32 or #36 French chest tube
(1) Coversite dressing (in an orange/white package, convenient square dressing for CT)

On any non-trauma unit

Except on 10-5 trauma, youll have the standard chest tube tray without the extras, in which case
you should gather all of the above as well as:

(1) bottle of betadyne (if allergic, then use chloraprep swab)
(1) #20 gauge needle
(1) #10 blade scalpel
(2) masks
(1) pleuravac
(1) vaseline gauze
(1) 0.0 or 2.0 silk or nylon suture

Sometimes, it seems like a waste to open the entire chest tube tray when all you really need are
a few components in it. In this case, gather all of the above as well as these instruments which
substitute for having the entire tray:

(1) Hemostat (for spreading/dissecting chest wall muscles after incision)
(1) Kelly clamp (for popping through into the pleural cavity)
** This can be gotten from CDC or from one of the trauma bay rooms **
(1) Needle holder (available in most supply rooms)
(1) Heavy scissors (available in all supply rooms) or Suture Removal Kit (has forceps)

Procedure

1. If you are using the chest tube tray, this will serve as your sterile field for all items

46 |G a t o r T r a u m a M a n u a l

2. Put on a hat and mask

3. Open the chest tube tray

4. Empty all sterile items onto this sterile field, including the #32 Fr chest tube
a. Emptying the chest tube without accidentally emptying it onto the ground or touching
the sterile field with the non-sterile casing is the trickiest part.

5. Lay the patient supine, raise arm above the head, and lower the side rails on
the side of interest

6. Degown the patient so that the entire axilla, upper arm, chest, and side are clear

7. Peel the metal foil top off of the bottle of lidocaine

8. Peel the lid off of a 4x4 gauze tub and pour half of the betadine bottle on top

9. Now youre ready to draw up lidocaine/prep/drape

10. Put on just one glove (dominant hand) and with this sterile hand, load the #20 needle onto the
10mL syringe. With your non-sterile hand, take the protecting cap off of the needle and throw the
cap away. Finally, pick up the lidocaine bottle with your non-sterile hand and draw up the
lidocaine yourself.
a. This is a neat trick you can use so that you dont depend on someone else in this
procedure to hold something for you, like the lidocaine bottle
b. You could skip step #10, put on both gloves, and just have the nurse help

11. Put the lidocaine down, taking note that the cap is no longer protected.

12. Put your other sterile glove on.

13. Prep the patient from upper chest to costal margin, include side, axilla, upper arm. Take care
not to touch non-sterile areas with your sterile gloves

14. Use four towels to drape: superior, inferior, medial, and lateral to prep area

15. Use the two small barrier sheets to drape the left and right side of the pt

16. For a standard chest tube, you want to enter around the 5
th
intercostal space, mid-axillary
line, which, for non-large breasted people, ends up being at nipple level. In large breasted
people, use the inframammary fold as the target level

17. Inject lidocaine one intercostal space below where your chest tube will ultimately enter the
pleural cavity. Create a 2-3cm diameter wheel in the skin, then inject the subcutaneous tissue as
well. If the patients thin enough, inject along the planned path of the dissection & chest tube
entry and numb up the periosteum. If the patients too big, save the periosteal injection until after
your incision.

18. Make a 2cm incision parallel to the intercostal space, one level below, through skin and
subcutaneous tissue.

19. Inject more lidocaine along the path mentioned above and the periosteum of the ribs above
and below the site of insertion. If you can, infiltrate the parietal pleura

20. Maximum dose of one percent lidocaine is 0.5mg/kg (remember this)

47 |G a t o r T r a u m a M a n u a l

21. Bluntly dissect through the muscles by spreading a Kelly clamp deliberately.
a. The motion is go in with clamp closed, spread, come out, close the clamp, then go in
again and repeat.
b. You should steadily be making your way toward that target intercostal
space, one level above where your incision is.

22. Once youre right above that rib, apply steady force at the superior aspect of the rib and pop
through into the pleural space.
a. One trick to prevent from going too deep is to keep your index finger
extended along the Kelly, close to the tip, so that as soon as you pop in,
your finger will hit the chest wall and prevent you from going any deeper
23. Dont remove the Kelly yet and spread the Kelly wide to spread apart the pleura and
intercostal muscles so that the path you created will stay open easier.

24. Remove the Kelly and then insert your finger through the tract both to confirm in your minds
eye where the path is and also to feel inside the pleural space and make sure there are no
adhesions between the lung and the pleural surface.
This is basically to make sure that the chest tube does not puncture lung and to verify that you
are in the chest (and not below the diaphragm).

25. Clamp the Kelly to just proximal to the end of the chest tube and guide the tube into the
pleural cavity. If you can fit your other finger, then use that finger to help guide the tube into the
right place and then confirm that its not in the sub-Q but in the pleural cavity.

26. For a pneumothorax, guide the tube anterior/apical. For hemothorax, the position should be
posterior/inferior

27. Confirm that the tubes in the pleural space by noting condensation in the tube with respiration
or by pleural fluid drainage from the tube.

28. The tube should go in to at least 12cm and feel with your finger along the tube to make sure
the sentinel hole is not outside of the pleural cavity in the subcutaneous space.

29. Close the skin around the tube with two sutures and anchor these to the chest tube i tself.

30. Once the tube is secured, hook it up to the Pleuravac.

31. Wrap the vaseline gauze around the entry site, then 4x4 gauze underneath and on top of the
tube, followed by the convenient Coversite or just tape.

32. Secure the tube further down at another site with tape and create a mesentery. This is so
that there isnt too much torque created at the painful
insertion site.

33. Dispose of your two syringe needles and the suture needle

34. Towels and barrier sheets go into the blue bin, all others go into the red bag.

35. Order a stat chest x-ray to determine chest tube position and interval change

36. Write a procedure note and update the list with the date & R CT placed

37. Log the case at the ACGME site. CPT code is 32020

38. Check for air-leak daily, only put to water seal if no air-leak

48 |G a t o r T r a u m a M a n u a l

39. In general, only discontinue the chest tube when output is < 150 cc/day and there is no air
leak.













































49 |G a t o r T r a u m a M a n u a l

Appendix IX: Trach/PEG from start to finish

1. If CCM is making the request, make sure the primary team is agrees.
2. Clarify the request: trach, trach/PEG, or PEG.
a. Fill out a consult
b. CC: ventilator-dependent respiratory failure and/or need for enteral feeding
access
c. Check for recent incisions or prior scars in the neck and abdomen since this may
affect the feasibility of performing the procedure
d. Know the prior surgeries
e. Check coagulation studies and platelet count
3. Obtain consent (dont wait on this, just get it done)
a. The SICU has a central clerk station with a binder for each POD which contains
the next of kin contact information
b. Unless theres an absolute contraindication to PEG placement, just obtain
consent for both tracheostomy and gastrostomy, percutaneous endoscopic
vs open and all indicated or related procedures and explain to the family that
we may be performing a stomach feeding tube at the same time
4. Let your chief resident and/or attending know about the consult and place it on the
main trauma list (not the Trach-PEG list his ones for Trach and PEGs that have
been done already)
5. The day before the planned procedure date, write an order saying:
a. Trach supplies to bedside
b. The First PEG: FastTrac PEG kit to bedside. There is a kit that we used to
use and the nurses will commonly pull this one out of habit. Make sure that they
get the specific kit named above from CDC (Central distribution)
c. Pavulon (pancuronium) 10mg IV x1 for planned Trach/PEG
d. Fentanyl 100-200mcg IV x1 for planned Trach/PEG
e. Versed 1-5mg IV x1 for planned Trach/PEG
f. If its a neurosurgery patient, they usually prefer Propofol (comes off quicker)
rather than Versed.
6. On the day of procedure, call Nate Curry at 260-7165 to inquire about availability of
the endoscope and when you need it (and for how long)

Medications

Pavulon paralytic agent
Propofol/Versed sedation agent
Morphine/Fentanyl analgesic agent
Lidocaine 1% with epinephrine, 20mL viallocal anesthetic


Trach/PEG supplies

Draping

(6) Sterile towels
(4) Sterile small barrier sheets
(4) Sterile gowns

Miscellaneous

(4) Masks
(4) Caps
(2) Normal saline flush
50 |G a t o r T r a u m a M a n u a l

(1) 10mL syringe
(1) #19 or 21 needle to draw up lidocaine
(1) #25 needle to inject lidocaine
(1) 1L bottle of saline for cleansing the endoscope after use
(1) Bowl to put the saline in for above
Sterile gloves

Supplies

(1) Betadine solution
(1) Blue Rhino tracheostomy kit
(1) Tracheostomy instrument tray
(1) sterile gauze (tub)
(1) #6 Cuffed Shiley tracheostomy (DCT)
(1) #8 Cuffed Shiley tracheostomy (DCT)
(1) Nu-Gauze bottle
(1) Velcro Tie band for tracheostomy (trach tie)
(1) Suction tubing, sterile
(1) Yankauer, sterile
(1) Electrocautery (Bovey) grounding pad
(1) Electrocautery (Bovey) pen
(1) Electrocautery (Bovey) machine
(1) Procedure light
(2) 0.0 (or 2.0) silk suture with cutting needle


Setting up the Trach/PEG

Now youve been told to go set up the Trach/PEG
The key to getting this done right is knowing which elements of the above supplies are commonly
missing or are commonly forgotten in the set-up, whether by us or nursing.
These include:

1% lidocaine with epinephrine bottle (can be pulled from the Suremed)
Silk sutures
Bovey grounding pad/pen/machine
Overhead procedure light
Wrong PEG kit (mentioned above)
Set-up for suction (canister mounted to wall suction)
Pavulon not obtained from pharmacy
Anesthesia/CCM not aware
Normal saline flush (to wet the big Blue Rhino dilator in the kit after its opened)
10mL syringe and #20 needle to draw up lidocaine and #25 needle to inject
Extra 4x4 gauze tub (youll use one to prep with and the other to open onto sterile field)

If its been awhile since you called Nate Curry, call again and remind him youre coming for the
Endoscope (located between rooms 23 and 22 in the main OR, main hallway)

1. Position the patient supine/flat.

2. In each POD, behind the crash cart, is a backboardplace this under the patients back
so that the neck will be hyperextended. If the neck is not cleared, then maintain the
head, neck, and shoulders in neutral position with IV bags and tape.

3. Take a blanket or two large towels and create a roll to put under the scapulas

51 |G a t o r T r a u m a M a n u a l

4. If the patients C-collar is not cleared, have the nurse administer the paralytic and remove
the collar.

5. Move the endotracheal tube away from the midline so its out of the way

6. De-gown the patient from neck down to pelvis (for Trach-PEG)
a. If only a Trach, just clear out the area from chin to sternum for prepping

7. Place the Bovey grounding pad on the patients buttock or thigh and hook it into the
machine.

8. Plug the Bovey machine and overhead procedure light into the outlet.

9. Put on a hat and mask.

10. Open up the Tracheostomy instrument tray (big tray wrapped in blue with sticker showing
that its been autoclaved/sterilized) this is now your sterile field over which you will open
all other sterile items for the procedure
11. Open the small barrier sheets(4), sterile towels(6), #8 cuffed shiley trach tube(1), suction
tubing(1), Yankhauer(1), Bovey pen(1), Silk sutures(2), 10mL syringe(1), #19/21
needle(1), and #25 needle(1)

12. n a non-sterile area, peel the lid off a 4x4 gauze tub, pour in half of the betadine bottle
(Make sure the patients not allergic to betadine or iodine, in which case you should use a
Chloraprep stick available in the supply rooms)

13. Now, youve opened everything you need to and youre ready to put on some sterile
gloves and prep/drape/draw up lidocaine

14. Put on sterile gloves and have a nurse to hold the lidocaine bottle while you draw it up
with the 10mL syringe and #20 needle, then load the #25 needle

15. While you have the nurse, have him/her open the Trach kit and place this on your sterile
field around the lower legs.
a. Then have the nurse wet the Blue Rhino dilator (has hydrophilic coating) by
empting one of the normal saline flushes onto it

16. Then put the Bovey pen on the field and have the nurse plug it into the machine and turn
on the Bovey machine. It will take 30 sec to load-up, then have the nurse place the Cut
and Coag to 40.

17. Prep the neck up to the chin and down to sternum for the trach. Prep the abdomen from
lower ribs down to pelvis for the PEG
a. Try not to let your sterile gloves touch non-sterile areas

18. Lay down towels in this fashion: One along the right side, one along the left side of the
neck, one transversely across the sternum (folded in half so you dont cover the
epigastrum of the abdomen which you need to keep clear for the PEG), one on the right
side of the abdomen, one on the left side of the abdomen, one transversely to serve the
inferior border of the PEG field.

19. Drapes(4) should expose neck to lower abomen.

20. Lay a towel across the abdomen to cover the area til youre ready to do the PEG

52 |G a t o r T r a u m a M a n u a l

21. Lay another towel down below the neck to serve as a field for the instruments youll use.
** place everything in the order you will use them (below)
a. Lidocaine in syringe + #25 needle (keep the needle capped/protected)
b. Blade/scalpel from the Trach kit
c. Adsons (pick-ups) with teeth
d. Bovey pen
e. 4x4 gauzes
f. Right angle instrument x1 (on the chiefs side)
g. Debakey pick-ups x2 (Dr. Armstrong likes to use these)
h. Army-Navy retractors x2
i. Mosquito or Hemostat x4 (two on the chiefs side, two on the junior residents
side).
i. Little trick: clamp these onto the towel so they wont fall off
ii. You can do the same with the Right angle instrument
j. #8 Tracheostomy tube
k. Trach kit
l. Silk sutures x2, Heavy scissors, Needle holder x2

22. Take the jelly packet out of the Trach kit and empty it onto the cuff/balloon on the trach
tube to lubricate it.

23. Now you are ready to call your chief resident and CCM. If theyre going to be awhile,
then cover everything to keep it sterile

24. Inject lidocaine in the skin and sub-Q two fingerbreadths above the sternal notch

25. Unglove and start filling out paperwork (procedure checklist) and do your time out.

26. Have the nurse administer the sedation and analgesic agents

27. Perform the tracheostomy

28. Dispose of your needles, but do not throw away the scissors or the lidocaine as you will
need these for the PEG.

29. Remove all other instruments except the:
a. Scissors
b. Lidocaine
c. Scalpel/Blade
d. Mosquito/Hemostat

30. Now were onto the PEG portion of the procedure

31. Place the patient at 60 degrees

32. *** Do not open the PEG kit until you have a good light reflex ***

33. Stay sterile while your Chief gets the scope ready (below are chief instructions)
a. put some saline in a bowl to clean the endoscope
b. plug in the endoscope and hook up suction to the scope as well
c. Untape the dobhoff tube and NGT (might want to just take out the NGT)
i. Try to preserve the dobhoff tube until you know youre going to get the
PEG successfully)

53 |G a t o r T r a u m a M a n u a l

34. Once the chief has the endoscope in the stomach, start poking around for a good light
reflex (it should give a strong red spot with mild to moderate amount of force). ** Turn off
all the lights for this **

35. If you have a good light reflex, have the nurse open up the PEG kit and take the tray as
well as the G-Tube underneath transfer to the sterile field

36. Open up the lubricant package and pour some into the hole of the little button

37. Take the G-tube and put the tapering blue tip straight into the lubricant package

38. Reconfirm the light reflex and hold your finger over the area.

39. Turn on the lights and inject lidocaine into the area under your finger. Make a wheal so
that you know where to cut

40. Make a 1cm transverse incision over this area

41. Take the Bovey and dissect further into the sub-Q

42. Take the mosquito and spread/dissect the tissue some more to clear a path

43. Now take the introducing needle from the PEG kit and while watching the endoscope
monitor, enter at a perpendicular(90 degree) angle into the stomach

44. Complete the PEG procedure

45. Suture these components down (essential):
a. Button (with four sutures on every side except the side where the tube is coming
off)
b. Suture the GTube right where it comes out of the button so this wont slip back in
and cause the stomach to peel away from the abdominal wall and give the
patient peritonitis/free air
c. Suture the rest of the tube in a Vogel fashion (Vogelize it)
d. Finally, suture the distal end of the G-Tube to secure the cap on the tube

46. Dispose of all of your sharps

47. All disposable non-sharps go in the red bag

48. All recyclable towels, sheets, etc go into the blue bag

49. Rest of the instruments plus the metal tray go into the instruments drop-off area in the
corner of each POD

50. Put the side rails up

51. De-gown and write a procedure note if the attending has not

52. Write orders for
a. medications given that were not previously ordered
b. tube feeds (If patient was on goal before, start at half goal 1 hour later, then
titrate up to goal immediately)
c. erythromycin 250mg PO/p-GT Q6H
d. abdominal binder at all times to cover the GT and prevent accidental pull
e. routine tracheostomy care
54 |G a t o r T r a u m a M a n u a l


53. Do the dictation (Appendix VII)

54. Once you do a post-op check and theres no active bleeding and all of the above are in
place, transfer the patient to the Trach-PEG list.










































Appendix X: EAST Trauma Practice Guidelines

http://www.east.org/tpg.asp
55 |G a t o r T r a u m a M a n u a l



Appendix XI: Door Codes

Shands Supply Room Codes Ward Access Code

ER 1225 (Christmas) 911
10-5 2233
PICU 1004 1004
95-MS 9995
94-IMC 2007 9400
75-MS 6126
74-MS 6124
72-BI (BICU) 2468 1958
64-MS 6127
65-MS 6123
55-MS 6111
54-MS 5115
45-MS 6131 4500
44-MS 6171
3300 (NICU) 0033
CICU 4015
SICU 2468 9111
MICU 5200
PACU 0038
Surgery Clinic 2015

Other Codes
Resident lounge 4326 (used to be 6789)
Any of our callrooms 421
Anesthesia workroom 113
Peds surgery callroom 633
OR locker room 911
CCM callroom 911
ER trauma bay 911
VA 4
th
fl callroom 333 or 886
VA 5
th
fl workroom 950
VA 5-Surg supply room 512
VA 1
st
fl callroom 886
VA simulator (main entry) 1597
VA simulator (lab) 5041
VA colonoscopy login first initial + last name (all lowercase), i.e. tkim
VA colonoscopy PW last four numbers of UFID
AGH lunchroom code 480612
AGH ER entry 3005* (hit star after the 4 numbers)
AGH secret backway 3005*
AGH PICU entry 1010*
AGH peds floor 1010* or 3005*

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