All posts by The Trauma Pro

Philosophy

When Is A Physician Too Old To Practice?

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There are about a quarter of a million physicians who are currently 65 or older and in practice. This represents about a quarter of those currently practicing. Unlike other professions like federal judges, FBI employees, and nuclear materials couriers, there is no mandatory retirement age for doctors. Although not forced to retire, commercial pilots are more closely monitored after they turn 65. But our profession has not really done a very good job of policing itself. It relies on voluntary action to identify struggling colleagues, who are generally reluctant to report a partner.

We are all living longer, and physicians are no exception. This means that many continue to practice well beyond the “customary” retirement age. What exactly happens to us? One study gave a quick cognitive test to a group of physicians and compared them to non-physician controls. Here are the results:

Ages ranged from 30-80 years. Note that the physician scores were consistently higher than the controls for all age groups, but declined significantly with age just like the controls. The big problem is that individuals have difficult recognizing (or accepting) their own cognitive decline.

The American College of Surgeons (ACS) assembled a workgroup to address this issue. They recommended that surgeons undergo voluntary, confidential testing of their baseline vision and physical examination starting at age 65-70, with regular re-evaluation afterwards. So far, only 3 or the more than 5,000 hospitals in the US do this. Canada has a mandatory age of 70 for commencing regular peer evaluations of competence. Obviously, the US does not.

There are really two components at play: wellness (which includes cognition) and competence. The problem is the neither correlates well with chronological age, but rather physiologic age. And the latter is impossible to quantify.

So what do we do? This is a problem that can’t be ignored from a patient safety standpoint. But it does not readily lend itself to simple pronouncements of a mandatory retirement age. There are many physicians who can and do provide excellent service to their patients well past the customary retirement age. They are able to apply a lifetime of lessons learned that their younger colleagues simply do not have.

We need uniform adoption of mandatory, not voluntary, testing of wellness and competence. Individual hospitals need to heed the recommendations of national organizations like the ACS to implement these mandatory programs to ensure fairness and avoid the specter of age discrimination lawsuits.

I’m no spring chicken anymore, and I think about this every time I find myself searching for the name of that weird retractor I need. How old is too old? What do you think?

Reference: The Aging Physician and the Medical Profession. JAMA Surgery 152(10):967-971, 2017.

Imaging, Resuscitation

ACS Trauma Abstract #6: Scanning Unstable Trauma Patients???

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If you’ve read my stuff for very long, you know I frown on sending unstable patients anywhere but to the OR. Instability tends to get worse, and that always happens at inopportune locations like hallways, elevators, and CT scanners. Imagine my surprise when I noticed an abstract being presented at the Clinical Congress of the American College of Surgeons this week suggesting that it was okay to scan hemodynamically unstable patients before “definitive therapy.”

Here’s the title:

“Computed tomography in hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage”

The devil is in the details and the language. This group from USC included all patients who were hemodynamically abnormal on arrival to the trauma bay but who normalized to SBP > 90 during the resuscitation were included.  A total of 253 of these patients were reviewed over a 9 year period, and the usual variables were analyzed (mortality, complications, hospital, ICU, and vent days, etc).

Here are the factoids:

  • Of the 253 patients studied, 45 went to straight to OR and 208 were taken to CT
  • Injury severity was identical for the two groups
  • Lengths of stay and mortality were not different, but only p values were given
  • Patients taken to CT cleared their lactic acidosis faster (12 vs 5 hours), and used a bit less plasma and significantly less blood transfusions
  • The OR group underwent more procedures (31% vs 13%), although what these were and when they were performed is not listed

Bottom line: The title of this abstract is misleading, and may fool those who don’t read the rest of the abstract. It should read:

“Computed tomography in previously hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage”

Someone who just skims through this issue of the journal may get the idea that it’s okay to scan an unstable patient. The authors are not saying this at all. If you read the conclusion carefully, you can see that the patients had to be resuscitated to a SBP > 90 before they considered taking to scan. And they did that for the majority of these patients.

The real question is, why do the scanned patients clear their lactic acidosis faster, need less blood, and undergo fewer procedures? It appears that there is some bias or selection process in play. Otherwise, why not use the magic CT scanner to make them all better?

Reference: Computed tomography in hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage. JACS 225(4S2):e175-176, 2017.

Imaging, Philosophy

If A Tree Falls In A Forest…

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After yesterday’s analysis of a not-so-good pan-scan vs selective-scan abstract, it’s time for a little philosophy today. There seem to be two camps in the world of initial diagnostic testing for trauma: selective scanning vs scan everything. I admit that I am one of the former. Yes, the more tests you do, the more things you will find. Some will be red herrings. Some may be true positives, but are they important? Here’s the key question:

“If a tree falls in a forest and no one is around, does it make a sound?”

There is a clinical corollary to this question in the field of trauma:

“If an injury exists but no one diagnoses it, does it make a difference (if there would be no change in treatment)?”

Here’s an example. On occasion, my colleagues want to order diagnostic studies that won’t make any clinical difference, in my opinion. A prime example is getting a chest CT after a simple blunt assault. A plain chest xray is routine, and if injuries are seen or the physical exam points to certain diagnoses, appropriate interventions should be taken. But adding a chest CT does not help. Nothing more than the usual pain management, pulmonary toilet, and an occasional chest tube will be needed, and those can be determined without the CT.

Trauma professionals need to realize that we don’t need to know absolutely every diagnosis that a patient has. Ones that need no treatment are of academic interest only, and can lead to accidental injury if we look for them too hard (radiation exposure, contrast reaction, extravasation into soft tissues to name a few). This is how we get started on the path to “defensive medicine.”

Bottom line: Think hard about every test you order. Consider what you are looking for, what you might find, and if it will change your management in any way. If it could, go ahead. But always consider the benefits versus the potential risks, or what I call the “juice to squeeze ratio.”

References:

  • George Berkeley, A Treatise Concerning the Principles of Human Knowledge, 1734, section 45.
  • paraphrased by William Fossett, Natural States, 1754.
Imaging

ACS Trauma Abstracts #5: Pan-scan vs Selective CT For Pediatric Patients

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In major adult blunt trauma, there are still two factions: those who pan-scan for diagnosis, and those who use CT selectively. The pan-scan proponents argue that they find everything, including things that would have been missed with selective scanning. The selective scanners argue that those things are typically not clinically significant, and radiation exposure is reduced.

Who is right? We’re still not sure. But when it comes to children, most believe that less radiation is always better. The group at USC decided to look at their experience with pan-scan vs selective imaging in blunt pediatric trauma patients, defined as those < 16 years of age. They reviewed their experience over a three year period, excluding those who had low blood pressure (<90). A total of 648 children met these criteria, and an array of variables were analyzed to try to determine “superiority.”

Here are the factoids:

  • 88% of these patients had low injury severity (ISS < 15), 567 patients
  • The low severity group who were selectively scanned had a half-day decrease in length of stay*, a quarter-day decrease in ventilator days, lower morbidity (15% vs 24%)*, and radiation exposure (8 vs 18 mSv)*, with the asterisked variables being “statistically significant”
  • The high severity also showed positive differences in decreased ICU length of stay, ventilator days, morbidity*, and radiation exposure*
  • For both pan- and selective-scanning, additional imaging led to no additional interventions in 95% of cases

Bottom line: Ugh! This is not a good abstract. It shows association, but not causation with anything but the radiation exposure calculations. Yes, if you scan less in the selective arm, there better be less exposure. But the other variables are either not clinically significant, or not defined well (i.e. morbidity).

The authors conclude that selective scanning is the way to go based on this (extremely weak) data. This is why I always recommend that you read the whole paper, not just the abstract, or in this case the whole abstract and not just the conclusion. The data, as presented in this abstract, do not support this at all.

The authors don’t say how many of these patients were very young, and how many of them actually received pan-scans. But any pediatric trauma surgeon would cringe if they read this  article. Although you may be a big believer in pan-scanning, reserve it for adults only until we have some better data. Don’t irradiate kids unnecessarily!

Reference: Selective CT imaging is superior to liberal CT imaging in the hemodynamically normal pediatric blunt trauma patient. JACS 225(4S1):562, 2017.

Pharmacy

ACS Trauma Abstracts #4: Timing Of DVT Prophylaxis In Spine Trauma

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Spine trauma is one of the high-risk indicators for deep venous thrombosis (DVT). Unfortunately, there is a great deal of variability in the start time for chemical prophylaxis for this injury, especially after the patient has undergone surgery. In part, this is due to a lack of good literature and guidelines, and in part due to the preferences of the spine surgeons who operate  on these patients.

A group at the University of Arizona in Tucson performed a large database review (looks like National Trauma Databank, although they don’t say in the abstract) looking at “early” vs “late” administration of prophylaxis after surgery in these patients. The spine injury was the predominant one, with all other systems having an abbreviated injury score (AIS) < 3. They matched two years worth of patients for demographics, initial vitals, type of operative intervention, and type of heparin to assess the impact of prophylaxis timing.

Here are the factoids:

  • Nearly 40,000 patient records were reviewed, and over 9,500 met the spine injury criteria with operation and prophylaxis. A total of 3,556 could be matched for analysis.
  • These patients were split in half for matching, late (>48 hrs) versus early (<48 hrs)
  • DVT rate was significantly lowe in the early prophylaxis group (2% vs 11%)
  • PE rate and mortality were the same between groups
  • Return to OR and blood transfusion rates were identical (1% and 1-2 units)

Bottom line: Once again, we see that “early” prophylaxis for DVT is probably desirable and mostly harmless, even after a spine operation. Many surgeons still have an irrational fear of giving heparin products in patients who have some risk of bleeding. The body of literature that supports early use just keeps growing. One observation, though: as in most other studies, pretty much whatever we do for DVT has a negligible impact on PE and mortality. We can only treat the clots, but not their major aftermath.

Reference:  Optimal timing of initiation of thromboprophylaxis in spinal trauma after operative intervention: – propensity-matched analysis. JACS 225(4S1):S59-S69, 2017.