Keeping Up with Trauma Care on the Web

Many medical students are initially attracted to emergency medicine because of trauma cases. The patient rolls into the bay, and is surrounded by doctors and nurses who work as a carefully coordinated team, examining and imaging every inch of the body for injury. Perhaps the student gets to start a large-bore intravenous catheter or place a Foley. It is thrilling, just like on television.FigureOne of the challenges of a medical student rotation in the emergency department is to correct the perception that trauma is more than a small part of emergency medicine without losing the poor souls to the department of surgery. We try to keep the sharp ones anyway. Residency training in emergency medicine includes several months of trauma experience. Graduates enter the workforce well prepared to take care of major trauma in the emergency department. Most EDs, however, are not trauma centers, and over time, the emergency physician may lose some of his clinical skills in dealing with trauma cases. ATLS courses provide good reviews and some hands-on experience, but what are you to do when that unexpected case comes crashing through your door? We all know to start with the ABCs, but what then? In this circumstance, having a well placed favorites list including trauma sites may contribute to a favorable outcome. Trauma.org (www.trauma.org) is a useful web site. International in scope and membership, according to what is posted, the site and associated mailing list were established in 1995. The site includes traumabank, imagebank, and moulage sections, as well as links to other resources and a short summary of four other web sites devoted to trauma and injury prevention. In the traumabank section, a well-indexed series of one- to two-page reviews are pithy enough to help you work up a trauma patient who is reasonably stable. In three clicks, you can obtain a guide to penetrating neck trauma that reminds you about zones 1 to 3 and the implications of each. There are short reviews of many other subjects, such as permissive hypotension and traumatic brain injury. Other summaries focus on operative techniques such as aortic patches and using plastic rods for open reduction and internal fixation. Perhaps more fun is the moulage section. Moulage, French for a mold or cast, in this context refers to simulation. Some trauma courses make use of human actors dressed as trauma victims. The students then simulate the care of the actor. Imagine the emergency medicine oral board exam but with the examiners bleeding and in pain. (Or maybe you already thought of this.) Moulage Section The moulage section of Trauma.org is divided into sections that include pediatrics, cervical spine clearance, neurotrauma, and prehospital care. In each scenario, you are given pieces of information at each step, and you must make clinical decisions as the scenario unfolds. At the end of the moulage, you get a summary of some of your mistakes.Table: Trauma Sites on the WebThere also is a moulage series devoted to trauma team leader decision scenarios. Cases are presented more completely up to a particular decision point, and you are asked to choose what comes next. Some of these are very simple. For example, an eviscerating stab wound to the abdomen needs which of these? ▪ Diagnostic peritoneal lavage. ▪ Laparotomy. ▪ FAST ultrasound. On the other hand, a patient in a high-speed motor vehicle crash with hypotension, tachycardia, and neurological signs indicating a cord injury has what? Hypovolemic, neurogenic, or spinal shock? (Which answer is not like the others?) Trauma.org also has an imagebank useful for preparing a lecture or making the nonmedical members of your household feel ill. The image section is organized by body part and system. Some of the images are intraoperative, but there are many with direct relevance to emergency medicine. Some have links to the email address of the physician who provided them. There is also a “What's New” section with monthly topics such as the new recombinant factor VIIa. November 2004 was devoted to the “VOMIT” syndrome, which stands for Victim Of Medical Imaging Technology. There are multiple images and scenarios that help define the term, but we are all familiar with the unnecessary chest radiograph that leads to the CT scan that leads to admission and perhaps even bronchoscopy or thoracic surgery. By definition, the work-up is ultimately negative, and the increasingly invasive tests are plagued with complications. Trauma Recommendations The Liverpool Trauma web site (www.swsahs.nsw.gov.au/livtrauma), published by the Liverpool Hospital Trauma Department, is another useful site to help us keep up with trauma recommendations. The Trauma Grapevine produces a journal following current topics of interest. The Grapevine has been around for 10 years and has many subjects. The most recent journal describes the diagnosis and management of traumatic liver injuries. The Trauma Cases section has 25 trauma cases with pertinent x-ray and special studies posted for discussion. The Trauma Handbook, although 10 years old, provides concise guidelines for trauma management. The Trauma Radiology section has a small number of useful images. The article, “Clearing the Cervical Spine,” is a bit dated but useful to review. The last journal cited is from 1995, which is before NEXUS and the Canadian C-Spine Rules. The Sudden Death section provides nine trauma cases where you must decide which management path to follow. Photos are provided to illustrate the clinical circumstances. The American Association for the Surgery of Trauma (www.aast.org) provides the abstracts of the lead articles in the Journal of Trauma. Even this small exposure can be enlightening, although it is not possible to read critically with only the abstract. The lead article in the April 2005 issue is concerned with sustaining the subspecialty of trauma surgery. The abstract includes the following: “Strategies to prevent the extinction of the trauma surgeon have focused on increasing the operative potential by including non-trauma general surgery emergencies. … To resurrect our discipline, we must reclaim and expand our operative potential and be relieved of our excessive night and weekend burden of serving as house staff for the neurosurgeons, orthopedic surgeons, and interventional radiologists.” eMedicine (www.emedicine.com) has 23 general trauma articles covering trauma scoring systems, transfusion and autotransfusion, penetrating neck trauma. and critical care in trauma. It also has many specific articles, such as ones on testicular trauma, globe rupture, and cervical fractures. Many of these articles are written with a level of detail very useful to busy EPs and include pathophysiology, clinical features, work-up guidelines, treatment recommendations, follow-up instructions, and medicolegal pitfalls. eMedicine continues to demonstrate the power of the Internet as its collection of articles grows. Full-view images are available only to paid subscribers, and their content is available for use in your PDA.

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