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In the context of trauma care, a pitfall refers to a trap providers may fall prey to, resulting in errors or adverse clinical outcomes. Particularly since the recent Institute of Medicine report underscored the importance of medical errors, the topic of system-based failures has drawn tremendous attention. Indeed, individual practitioners are increasingly being regarded as elements in a complex system of care, as opposed to self-contained sources of error. As a result, the highly structured training and simulation programs used by commercial aviation and the space industry have increasingly been examined by the medical field in an effort to reduce errors.

Each aspect of trauma care, from the initial resuscitation to rehabilitation, brings with it a host of challenges to practitioners and the system in which they work. The pace, variety of venues, and multidisciplinary nature of the field combine to create a complexity that makes for a system laden with potential pitfalls, latent and otherwise.

There are common threads essential to combating pitfalls in this type of environment: The first involves making provisions for examination, scrutiny, and adaptability of a trauma system with appropriate response times, expertise, and resources. Next is the establishment and maintenance of interdisciplinary communication, particularly during resuscitations and in the operating room. In addition, the development of a “water-tight” system of tertiary surveillance following the initial management is an important safeguard. Finally, a comprehensive management scheme for the trauma patient demands attention to issues of reentry into society, including matters of finances and psychological well-being.

A trauma system is complex, with a myriad of vulnerabilities due to the criticality of the patients, the unpredictable nature of the disease or condition, the time-sensitive nature of the treatment required, and the coordinated multidisciplinary needs of the patient. It is important that practitioners operating within this environment recognize the potential threats and system failures that constitute the pitfalls and that contribute to errors. One of the important characteristics of complex systems is that catastrophic failure within the system of care typically requires multiple points of failure, very much like mishaps in commercial aviation. The popular model used to illustrate how failure occurs in these complex systems is often referred to as the “Swiss cheese” model. In this construct, there is an ongoing series of events and threats spun off by the environment. These events and threats encounter layers of safeguards or defenses, each with its own unique set of gaps and deficiencies. Under normal circumstances 1 or more safeguards prevents the catastrophic failure of the system, but occasionally, the gaps and deficiencies may come together at a single point, and catastrophic failure may result. It is important that humans, with all their proclivities to error, recognize that they are part of this environment, and will inherently create both risks and defenses.

The general mindset in the approach to the trauma patient may be best characterized by the old dictum “assume nothing, trust no one.” The high incidence of clinically occult, potentially life-threatening injuries encountered in the management of major trauma victims dictates that patients should typically be managed according to the worst reasonable case scenario. Unlike some areas of surgical practice, the physical examination is the most critical, with the history often being less reliable. Constant reassessment of patients is mandatory, and the “clock speed” for diagnosis and treatment is critical. Recognizing the potential for errors, even the certainty of the diagnosis and the “sanctity” of a given operation should be regarded with a measure of skepticism.

In addition to the potential for individual failures and errors, the breakdown of team dynamics may occur in highly charged situations such as the resuscitation room or the operating room. Lessons learned from commercial aviation are likely applicable to behavior modification and improvement in these situations. Strong decisive leadership, clear, concise communications, the encouraged assertiveness of team members, appropriate workload assignments, and constant situational assessment of both patient and team status are among the important elements for optimal team dynamics.

Many pitfalls in the early resuscitation phase of trauma management stem from diagnostic or decision failures that occur during initial management. Unrecognized prehospital or resuscitation room esophageal intubations may be related to the lack of appropriate end-tidal CO₂ monitoring or inadequate ongoing training of prehospital personnel. The failure to recognize shock is often related to erroneous assumptions and incorrect attribution of the observed acidosis or hypotension. Misleading clinical signs such as intermittently normal blood pressure, the talking patient, or a disregard of physical findings or chemical indicators suggesting critical condition are among the important errors that lead to failure to recognize and adequately treat shock.

In critical airway management situations, careful coordination between emergency medicine, surgical, and anesthesiology teams is critical. The technique for optimal airway management has not yet been defined and will continue to vary as a function of provider experience, training, and local practice patterns. Rescue ventilation using Combi-tubes, percutaneous dilational tracheostomy via the Seldinger approach, and the traditional surgical cricothyroidotomy all offer advantages and decisions regarding the proper approach should ideally be worked out by the trauma team ahead of time.

Failure to properly assess the abdomen continues to be a problem and historically is one of the most frequently encountered errors in the early management of the trauma patient. An historical over-reliance on the physical examination has been replaced to some degree by a new over-reliance on imaging including focused abdominal sonography for trauma (FAST) and computed tomography (CT). The practice of routine torso scanning for even more minor mechanisms is becoming more commonplace and, while acting to reduce certain types of missed-injury errors, may be creating separate problems related to false positive studies.

Eliminating missed injuries and delayed diagnoses remain a challenge in a trauma practice. Some of the more common problems encountered include missed cervical spine injuries due to over-reliance on the physical examination in the face of impaired mentation, occult traumatic brain injuries, particularly in the elderly patient, blunt cerebrovascular injuries associated with head and/or neck injuries, unrecognized or untreated blunt aortic injuries due to an insufficiently high threshold to initiate CT screening, and the missed blunt intestinal injury resulting from lack of imaging sensitivity for this injury.

The very young and the very old often create physiologic traps. These include an altered hemodynamic response with a tendency to not manifest hypotension until advanced shock is present, and the relative intolerance of pain, hypoxia, or hemorrhage. The tolerance of elderly patients to even what would normally be minor physiologic aberrations is also small, and the tendency to treat the elderly in a manner similar to younger patients should be resisted. Undermonitoring may be associated with otherwise preventable mortality and morbidity, and the “latent” failures with respect to the elderly may be minimized by a more protocolized approach.

Pitfalls in the operating room are among the most basic and important: failure to maintain homeostasis and keep the patient out of shock, and the related problem of maintaining a hemostatic resuscitation with well-executed massive transfusions protocol and maintenance of an uninterrupted supply of blood and blood products. Failure of or delayed recognition of the cumulative effects of shock coagulopathy acidosis and the needs of massive transfusion may lead to preventable operative deaths. Deferral of definitive repair of selected injuries, in the interest of preventing further intraoperative physiological decline, is termed “damage control” and has been widely embraced from a philosophical standpoint. Losses in effectiveness may occur, however, if the damage control procedure is not terminated in a timely manner.

The conduct of so-called crash laparotomy in the setting of massive intra-abdominal injury and hemorrhage is perhaps 1 of the most critical elements in operative trauma management. Lack of proper prioritization and the strategic approach to selected injuries such as severe liver, pancreas, or gastrointestinal injuries may result in excessive hemorrhage and a worsened physiologic condition. Slow, methodical, distracted, or misplaced operative maneuvers, or an inappropriately placed reliance on definitive repair, are also common errors. Specific instruction in critical intraoperative decision making, coupled with animal-based technical skills courses, may offer the opportunity for surgeons to become more comfortable with these infrequently encountered situations.

Thoracic injuries occasionally pose unique opportunities for trouble. Delayed response to pericardial decompression for tamponade, even in the absence of significant hypotension, may produce progressive (and clinically occult) myocardial ischemia, potentially compromising outcomes. The simple oversewing of the pleural surface in penetrating lung injuries, when thoracotomy is required for hemorrhage, may precipitate lethal air embolism, and even mild over-resuscitation in the setting of more severe pulmonary contusions may have major consequences in the form of acute lung injury and adult respiratory distress syndrome (ARDS).

Missed injuries in the operating room continue to occur with predictable regularity. Small bowel lacerations overlooked in the setting of mesenteric hematomas, colon contusions with subsequent breakdown, visceral pseudoaneurysms that may not be apparent at operation, subtle injuries to the main pancreatic duct, and missed rectal injuries due to inappropriate intraluminal visualization are among these. In most cases, these intraoperative misses are avoidable through the use of simple technical maneuvers, basic diagnostic tests, or both.

Extremity vascular injuries, unless associated with major hemorrhage, are sometimes relegated to a more leisurely diagnostic evaluation. In the setting of vascular disruption, resulting limb ischemia or ischemic neuropathy may result from this delay. Postoperative failure to assess for the development of compartment syndrome may result in similar ischemia and muscle, or even limb loss. The rule of “maintaining clock speed” for both diagnosis and treatment applies particularly to these injuries.

In the postoperative and critical care phase, undermonitoring or misinterpretation of established monitoring parameters may result in both over- and under-resuscitation even among more experienced practitioners. Although prospective, randomized data have yet to establish the efficacy of goal-directed therapy in the resuscitation of major trauma patients, a goal-directed approach may act to standardize monitoring in these patients, and may be important in avoiding errors of under-resuscitation. Recent studies examining fluid-liberal or fluid-conservative strategies postoperatively in critically ill patients suggests that a more conservative strategy for fluid resuscitation is associated with shorter duration of mechanical ventilation and improved lung function, and may need to be considered in the context of goal-directed trauma resuscitation.

The development of protocols for the treatment of acute lung injury and ARDS has moved from a research instrument to routine clinical management guidelines. The most serious problem with these guidelines, however, is often the effective implementation and maintenance of a high level of compliance. Failure to do this, particularly for clinically proven modalities, is perhaps 1 of the most frequently encountered system “failures” in the critical care arena.

Although a discussion of pitfalls tends to focus on individual providers, including their function within a larger system of care, a more global and increasingly more serious pitfall for the entire trauma system is limited access to trauma care. By some estimates, more than one third of critically injured patients in many states or regions never reach a designated center. Despite increasing emphasis at the federal level on the development of trauma systems, trauma centers continue to close due to lack of physician commitment and appropriate financial support. Although the recent Institute of Medicine report details problems with access to care including overcrowding, uncompensated care, and specialist availability, it remains to be seen whether these problems, in the context of a trauma system, are reparable without more dramatic health-care reform.