All posts by TheTraumaPro

What The Heck Is It? #1

Here’s a perfect item for April Fool’s Day, although it is for real. The xray below was a pelvic image obtained during a trauma team activation. I’m not going to give you any more information than that. 

You’ve got until Monday to figure out what’s doesn’t belong and give me an answer in the comments. I’ll post the full story and answer then.

What The Heck #1

Reporting Unsafe Drivers: Part 2

So what should you do if you encounter a patient that really shouldn’t be driving? First, encourage them and/or their family to self-report. If that fails, familiarize yourself with the laws of your state (or province). 

In the US, 11 states have mandatory reporting laws for certain conditions that would impair driving. Forty have some type of reporting system for phsyicians and other health professionals. Many allow anyone to report. However, a few stipulate that they may release your name to the driver or that you must have their permission to report. This is essentially the same as not allowing you to report.

Unfortunately, only 29 states hold you harmless from civil or criminal suit if you choose to report. I suspect it would be a tough sell convincing a jury that a patient’s inconvenience is more important than protecting them from an unsafe driver, though. I doubt such a suit would go anywhere.

So brush up on the laws and procedures in your state and decide what is in your patient’s (and the public’s) best interest. Then do the right thing.

A sample of my compiled report of US state reporting laws is shown below. Click it or this link to download it.

To read Part 1 of this article, click here.

Sample state driver license laws

References: 

  1. Physician’s Guide to Assessing and Counseling Older Drivers 2e. NHTSA / AMA, 2010.

Reporting Unsafe Drivers: Part 1

We’ve all taken care of patients that either have a baseline condition or have sustained an injury that renders them unfit to drive. What issues need to be considered with regard to keeping them off the road?

There are a number of ethical and legal considerations. As a physician or other healthcare provider, you have three priorities. In order, they are:

  • Duty to protect your patient
  • Duty to protect the public
  • Duty to maintain patient confidentiality

Note that the duty to protect the public supersedes the need to maintain confidentiality. However, if the patient knows that their confidentiality may be violated, they may be less likely to seek treatment, disclose key information, or trust you.

The ideal method of dealing with a driver whom you believe is unsafe is to have a frank discussion with them (and their family, if permitted) regarding why you think they should stop driving and the consequences of failing to do so. They should be encouraged to stop driving voluntarily, or self-report to the license bureau so they can be re-evaluated. It is also very important to encourage the family to support the decision and provide alternative transportation to meet your patient’s needs. Social services should be involved so that transportation alternatives and resources can be provided.

If your patient refuses to surrender their license or self-report for retesting, then you need to consider reporting them to the license bureau yourself. Before doing this you should exhaust all possibility that the patient will stop driving voluntarily. You must also be knowledgeable of your state laws so you know what kind of protections (if any) are given to you after reporting.

Tomorrow, I’ll give a state by state description of the applicable reporting laws and a sample letter to send to the license bureau. Click here to view.

Controlling Fever In Head Injury

Fever is a well recognized side effect of head injury. Management of fever is inconsistent among physicians taking care of these patients. There is a lot of debate on the best course of action, but not so much data. Current enthusiasm for applications of hypothermia has created some reluctance to tolerate much in the way of hyperthermia. Here is my take on the currently available literature.

First, understand that there is a fundamental difference between studies that study induced hyperthermia vs those that look at spontaneous fever. This lies in the fact that the set point for temperature regulation is changed in fever, but not in hyperthermia. Therefore, it is not clear whether hyperthermia studies can truly be used to answer these questions.

Animal studies originally focused on stroke models, which showed deleterious effects from hyperthermia. TBI is very different than stroke, but some hyperthermia models did tend to show cellular damage and blood brain barrier breakdown at temperatures of 39C. However, a fever model in rats showed no outcome difference (in rats) in febrile vs normothermic animals with TBI.

A Medline search (ref 4) yielded no randomized controlled trials that could be used to guide us with regard to fever management. The lesser quality papers involved a very heterogeneous group of subjects that made it difficult to draw good conclusions. As a generalization, they found that extremes of temperature, both high and low, were probably associated with worse outcomes. One randomized prospective study showed that aggressive fever control for temperatures > 38.5C had higher mortality and more infections.

A recent meta-analysis (ref 3) found that TBI patients with fever stayed in the hospital and ICU longer. This translated into an extra $14,000 per patient. Precise reasons for the longer stay cannot be accurately determined, but it might be expected that patients with fever would undergo time-consuming searches for possible infectious sources.

Finally, a very recent prospective study (ref 1) at a single institution that did not try to alter temperature found that the optimum survival occurred in a group of patients whose temperatures remained between 36.5 and 38C.

Bottom line: Literature support for aggressive management of fever is poor. If there were a clear correlation with temperature maintained at or slightly below normal, we’d probably have figured it by now. Fever up to 38 degrees C probably does not need to be treated in head injured patients. However, this does not eliminate the need to continue surveillance for infectious complications.

References:

  1. The effect of spontaneuous alterations in brain temperature on outcome: a prospective observational cohort study in patients with severe traumatic brain injury. J Neurotrauma 27(12):2157-2164, 2010.
  2. Induced normothermia attenuates intracranial hypertension and reduces fever burden after severe traumatic brain injury. Neurocrit Care 11(1):82-87, 2009.
  3. Brain injury and fever: hospital length of stay and cost outcomes. J Intensive Care Med 24(2):131-139, 2009.
  4. The significance of altered temperature after traumatic brain injury: an analysis of investigations in experimental and human studies: part 2. Br J Neurosurg 22(4):497-507, 2008.

Is It A Trauma Center Or A Coffee Shop?

Tim Horton’s is a large franchise operation that runs about 3,750 coffee shops / restaurants in the US and Canada. Some of these franchises are located inside other establishments, such as hospitals. The outlet in the Royal Columbian Hospital in New Westminster, British Columbia, Canada is one such location, and it did double duty last month. Royal Columbian is the region’s trauma centre.

Due to a large number of patients being treated in the ED and some fly-ins from earlier in the day, the coffee shop was cleaned and converted to overflow for patient care. Six stretchers with privacy screens were set up and four patients were treated in the area. This situation lasted for about 90 minutes until the overcrowding eased. The shop was cleaned once again and ready to open normally the next morning, serving coffee, not patients.

Reference: BC Local News (www.bclocalnews.com)