Category Archives: General

Geriatric Week 4: The Medical Orthopaedic Trauma Service

Our population is aging, and falls continue to be a leading cause of injury and morbidity in the elderly. Unfortunately, many elders have significant medical conditions that make them more likely to suffer unfortunate complications from their injuries and the procedures that repair them.

A few hospitals around the world are applying a more multidisciplinary approach than the traditional model. One example is the Medical Orthopaedic Trauma Service (MOTS) at New York-Presbyterian Hospital/Weill Cornell Medical Center. Any elderly patient who has suffered a fracture is seen in the ED by both an emergency physician and a hospitalist from the MOTS team. Once in the hospital, the hospitalist and orthopaedic surgeon try to determine the reason for the fall, assess for risk factors such as osteoporosis, provide comprehensive medical management, provide pain control, and of course, fix the fracture.

This medical center recently published a paper looking at their success with this model. They retrospectively reviewed 306 patients with femur fractures involving the greater trochanter. They looked at complications, length of stay, readmission rate and post-discharge mortality. No change in length of stay was noted, but there were significantly fewer complications, specifically catheter associated urinary tract infections and arrhythmias. The readmission rate was somewhat shorter in the MOTS group, but did not quite achieve significance with regression analysis.

Bottom line: This type of multidisciplinary approach to these fragile patients makes sense. Hospitalists, especially those with geriatric experience, can have a significant impact on the safety and outcomes of these patients. But even beyond this, all trauma professionals need to look for and correct the reasons for the fall, not just fix the bones and send our elders home. This responsibility starts in the field with prehospital providers, and continues with hospital through the entire inpatient stay.

Reference: The medical orthopaedic service (MOTS): an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures. J Orthopaedic Trauma, 26(6):379-383, 2012.

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Next Week: Trauma In The Elderly

All of next week, I’ll be writing about a topic that is becoming more and more important: geriatric trauma. Our population is aging, and the number of older patients being admitted to trauma centers is exploding.

Here are the topics to be covered:

  • How We Take Care Of Our Elders
  • Thoughts On Geriatric Trauma
  • Elderly Trauma And The Frailty Index
  • The Medical Orthopaedic Trauma Service
  • Falls In The Elderly: The Consequences
  • Effect Of an In-Hospital Falls Prevention Program

And please feel free to leave comments and suggest future topics!

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EAST 2017 #14: Long Term Consequences of Trauma: Why Aren’t We Looking?

I’m adding one more post to my EAST 2017 collection. This one struck me because it dovetails with another one I analyzed last week. After hearing both, something just clicked. The first was “When is mild TBI not so mild”, and opened my eyes to the fact that more TBI patients had ongoing problems than I imagined.

Now I just heard a presentation that looked at long term functional outcomes in patients with ISS > 9 at Brigham and Women’s Hospital. They identified patients in their trauma registry from 6 and 12 months prior to the study, and called these patients to administer several standard evaluation tools. Of 394 eligible patients, 27% could not be contacted, and 30% declined to participate, leaving 171 subjects. Half were 6 months out from their discharge, and half were a year  out.

The findings were very interesting. Here are the factoids:

  • 23% had a positive PTSD screen at 6 months, but this decreased to 16% at one year
  • A quarter of patients were still living with assistance that they did not need preinjury in both time periods
  • 20% of patients experienced a change in insurance
  • Half of the patients stopped working due to their injury, and this did not improve at one year
  • One in six were readmitted at some point for their injuries
  • The majority used some type of rehabilitation service (inpatient or outpatient) during their recovery

Bottom line: In my mind, this is a very big deal. All trauma centers collect a huge amount of data to monitor how things work while the patient is in the hospital. However, once discharged, they are on their own. We have no idea how they are doing, we have no mechanisms for finding out, and we have no systems in place to help if there are problems.

It is certainly simple enough to schedule a few phone calls at time intervals after discharge. We have tools and screening questions that we can ask. We can even include this information in the trauma registry and trend it. But then what?

This problem reaches beyond the trauma centers. Sure, we can make referrals for PTSD and rehab services. But what about the patient’s job, or their insurance? What if they don’t have insurance coverage or funds for needed services?

I believe that trauma centers should develop these processes and start collecting this information now. But we will also have to work with community and social service resources in order to marshal the services that our patients require. 

Reference: Routine inclusion of long-term functional and patient reported outcomes into trauma registries: can this be done? Paper #34, EAST 2017.

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EAST 2017 #2: CT Scan After Recent Operative Exploration for Penetrating Trauma

The general rule for penetrating trauma, especially gunshots to the abdomen, is that you don’t need to obtain a CT scan to help you decide to go to the OR. (Of course, there are a few exceptions.) And the corollary has always been that you don’t need to get a CT scan after you operate for penetrating trauma.

But the group at UCSF is questioning this. They retrospectively looked at 5 years of data on patients who underwent trauma laparotomy without preoperative imaging. They focused on new findings on CT that were not reported during the initial operation.

Here are the factoids:

  • 230 of 328 patients undergoing a trauma lap did not have preop imaging
  • 85 of the 230 patients (37%) underwent immediate postop CT scan. These patients tended to have a gunshot mechanism and higher injury severity score.
  • Unreported injuries were found in 45% (!) and tended to be GU and orthopedic in nature
  • 47% of those with unreported injuries found required some sort of intervention

Bottom line: This is a very interesting and potentially practice changing study. However, there is some opportunity for bias since only select patients underwent postop scanning. Nevertheless, one in five patients who did get a postop scan had an injury that required some sort of intervention. This study begs to be reworked to further support it, and to develop specific criteria for postop scanning.

Questions/comments for the authors/presenters:

  • Be sure to break down your results by gunshot vs stab. This will help formulate those criteria I mentioned above.
  • Specifically list the occult injuries and interventions required. In some studies, those “required interventions” are pretty weak (urology consult vs an actual procedure).
  • How exactly did the operating surgeons determine who to send to CT? Was it surgeon-specific (i.e. one surgeon always did, another never did)? Was it due to operative findings (hole near the kidney)? This is also needed when developing specific criteria for postop imaging.
  • Nice poster!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Routine tomography after recent operative exploration for penetrating trauma: what injuries do we miss?  Poster #14, EAST 2017.

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EAST 2017 Page on The Trauma Pro Blog

Hello all! I’ve created a separate page for posts regarding the upcoming meeting of the Eastern Association for the Surgery of Trauma.

I will be reviewing a baker’s dozen abstracts over the next 2 weeks, giving my own analysis and commentary. I’ll also provide some suggestions and questions to anticipate for the authors to refer to.

Click here to visit the EAST 2017 page!

And if you are a presenter and would like me to look at your paper, just email, tweet, or connect via your method of choice.

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