The trauma service has a lot of paperwork associated with it. There’s a three-page form to fill in when the patient is admitted. Obviously, when you’re first trying to stabilize the patient, there’s no time to fill in forms, so these tend to get written when the team is waiting around in the CT scanner (there’s a¬†law engraven in stone, that at least one trauma resident must be with the patient at all times until they’re finally dispositioned, due to way too many bad experiences with patients coding, seizing, freaking out, or having serious neurological deteriorations while going through CT; even when it’s located inside the ER, any branch of the radiology department has the capacity to seriously impact a patient’s condition; we don’t call it the cave of death for nothing).

The nurse is there filling out her papers too, and the scanner techs have forms as well, so it starts to sound like a game of Go Fish:
Tech: “What’s the medical record number?”
Resident: “Here you go, it’s 18009834321232; what time is it right now?”
Nurse: “What size did you say their pupils were?”
Resident: “4mm, reactive to 2mm bilaterally; what were the admission vital signs?”
Nurse: “36.5, 89, 112/54. What scans are we doing?”
Tech (exasperated): “The same scans we do on every single trauma patient who comes through here, regardless of their mechanism of injury.”
Resident: “Hey, don’t look at me, that’s the chairman’s policy; we’ve been trying to explain to him for ten years that someone who fell down the steps and landed on their bum doesn’t need their belly scanned for a splenic rupture, or that people who got shot in the belly don’t need their head and neck scanned for epidural hematomas or Cspine fractures.”
Attending walks in the door: “What were you saying? Let me tell you about the octagenarian I took care of who fell out of a wheelchair and ruptured his spleen. . .”
Resident, sotto voce: “There is such a thing as clinical suspicion, physical exam, and directing your scans based on lab results and xrays, rather than giving everyone enough radiation to cure a low-grade case of lymphoma.”
Attending: “Did you finish the form yet? Did you look at the cspine scan? Is there a spinal cord injury? Is the spleen ruptured? Do we need to call the OR? Stop gossiping and do some work around here, people!”

Then there’s the form to be filled out when a patient is transferred from the ICU to the floor. Lately, due to a surplus of work to be done in the ICU, we’ve been rather remiss about filling these out. At first, this led to complaints from the floor team to the attendings, which led to a rather nasty reaming-out during morning report.

After that, I think the floor folks felt bad about getting us yelled at so much, but they still wanted their updates about patients being transferred, which leads to whispered conversations in the hallway when we think that particular attending won’t notice:
PA: “What exactly surgeries did he have while he was in the unit?”
Me: “As far as I can tell, he had his spleen taken out, and then something happened which turned the wound into a disaster, and he spent the next two weeks with an open abdomen, before we put a vac and a whitman patch on it, and then it finally got closed one week before I sent him upstairs.”
PA: “But exactly how many times did he go to the OR, because the insurance company wants to know for their records?”
Me: “I honestly have no idea; I don’t think they dictated op notes every single time, because things didn’t really change for a while; and then there were all the vac changes/whitman patch advancements at the bedside – do those count? And anyway, I came on service after everything had been closed, so I don’t know.”
PA: “Did he ever get the post-splenectomy vaccines?”
Me, feeling bad because this is really important, and could lead to the dreaded OPSSS (overwhelming post-splenectomy sepsis syndrome) if we don’t get it right: “I don’t know, shouldn’t that be in the nursing or pharmacology records?”
PA: “Yes, but his chart was so thick it got edited three times, and all the important pieces are missing.”
Me: “Well then, just give them to him again, I’m sure it won’t hurt anything.”
Attending, coming around the corner: “What’s going on here?”
Me: “Um, we were just. . . discussing post-splenectomy vaccines, sir.”
Attending: “Good, give us a power-point presentation tomorrow morning about the indications for vaccines, and how long after splenectomy they ought to be given.” (Which is not funny, because there’s a big controversy about this, since the best immunological response is if you give the vaccines before taking the spleen out, but obviously in trauma you can’t plan that; next best is to do it 10-14 days after surgery, when they’ve gotten over the stress of surgery; but many people advocate doing it 1-2 days after surgery, so they don’t get discharged from the hospital and lost to followup and never get the vaccines at all.)
Me, to the PA, ironically: “Catch me ever talking to anyone in the hallway again!”

My favorite is the form documenting a patient’s risk factors for developing a DVT/PE, and what we plan to do about it. They’re so nice, because once you finish filling them out, and inform the attending that based on the results you plan to a) use only SCDs (sequential compression devices) on the patient’s legs, b) give them subq heparin, c) scan their legs regularly for DVTs, d) prophylactically place an IVC filter, one of the attendings is guaranteed to respond: “That form is all nonsense anyway. Just give them lovenox. I don’t care what the contraindications are, lovenox takes care of everything.” Ah, that’s great, could you just write that on the bottom of the form, or better yet, make it so I don’t have to fill out the form, since you’re going to have the same answer anyway?

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