Category Archives: General

Do Trauma Surgeons Really Get Sued More Often? Part Two

There has always been a perception that trauma patients sue more often than other patients, and that trauma surgeons get sued more often than surgeons who do not provide trauma care. In several surveys polling surgical residents, this perceived malpractice risk is an impediment to considering a trauma practice. It is also frequently cited as a reason why established general surgeons do not want to engage in trauma care.

It is difficult to objectively study this area. Data sources are few and far between, and it is often difficult to get denominator information to determine the true incidence of lawsuits against trauma surgeons.

The University of Texas at San Antonio performed a nice study looking at their experience over a 12 year period. They compared the number of malpractice actions brought by patients who were undergoing an elective general surgical procedure, patients who underwent urgent or emergent general surgical procedures, and those who were classified as trauma patients.

They found that there were only 21 lawsuits served over the 12 year period, during which over 62,000 operations were performed. Seven were dismissed, 3 were granted summary judgments in favor of the physicians, and one went to trial and was decided in favor of the surgeon. Only half (10) were decided in favor of the patient. All were settled, with a total of $4.7 million in payouts. Legal defense costs were $1.3 million.

The ratios of lawsuits to operations performed were 3.0/100,000 for elective, 2.3/100,000 for urgent/emergent, and 3.1/100,000 for trauma. Given the total number of trauma patients evaluated, the ratio was 0.34 lawsuits per 100,000 trauma patients per year.

The bottom line: Health care is a complicated process, and there are bound to be a few adverse outcomes. The majority of these occur due to reasons that we do not yet fully understand. Lawsuits are rare, and as long as the physicians adhere to the standard of care, they frequently prevail. The idea that trauma surgeons get sued more frequently or more successfully than our non-trauma surgical colleagues is a fallacy that needs to finally be laid to rest.

Related post: Do trauma surgeons really get sued more often? Part one

Reference: Stewart et al. Trauma Surgery Malpractice Risk: Perception vs Reality. Annals of Surgery 241(6):969, 2005.

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Do Trauma Surgeons Really Get Sued More Often? Part One

The graph above shows the incidence of lawsuits for a variety of medical specialties. General surgeons are in the middle of the pack. Although all trauma surgeons are general surgeons, not all general surgeons are trauma surgeons. This means that it is possible that the true lawsuit risk of this small minority of general surgeons is masked. 

Tomorrow I will look more specifically at the malpractice risk of trauma surgeons alone. 

Related post: Do trauma surgeons really get sued more often? Part two.

Reference: Medical Board of California Annual Report, 2008-2009.

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(In)appropriate Neurosurgical Consultation

Emergency physicians and trauma surgeons routinely assess patients with potential neurotrauma and decide whether to obtain CT scans and/or neurosurgical consultations. The criteria they use to make these decisions are not always clear.

The neurosurgery department at the University of California – Davis performed a prospective study that looked at the appropriateness of consults they received and of CTs of the head ordered by other physicians in trauma and non-trauma patients. A total of 99 patients entered the study (32 head trauma, 29 spine trauma, 34 other disease, 4 not documented).

After reviewing the consultations, they found that 69 were appropriate, 32 were not appropriate, and 7 could not be classified. Additionally, they felt that 10 of the head CTs in injured patients (31%) were not indicated.

“Appropriateness” was difficult to define well in this study, and there is certainly a great deal of subjectivity involved. The authors recommend using the Canadian CT Head Rule to fine-tune use of head CT in trauma patients.

The bottom line: 1 in 4 consults were not appropriate, and 1 in 3 head CTs were not indicated. Despite its flaws, this study shows that we need to be better at evaluating our patients to reduce unnecessary consults and radiation!

Reference: (In)appropriate neurosurgical consultation. van Essen et al. Clinical Neurology and Neurosurgery. In press, for publication 10/2010.

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GI Contrast In CT Scanning for Blunt Trauma

Torso CT scanning has become a mainstay in the evaluation of major blunt trauma. The question of using GI contrast in these CTs arises from time to time. There is an ongoing battle between the ED physician/trauma surgeon, who want quick clinical and relevant results, and the radiologist, who wants nice pictures and a comprehensive list of diagnoses.

IV contrast is so helpful and immediately available that it is virtually a no-brainer to use. The only exception is in patients who have a known allergy to it. GI contrast is more complicated. Ideally, it should be given in divided doses over about an hour, and there just isn’t time for it in trauma patients.

We designed a prospective, randomized study more than 10 years ago that looked at groups of patients who either did or did not receive oral contrast. We studied 394 patients and looked a the need for laparotomy based on study results, delayed diagnoses, and nausea/vomiting.

Thirteen percent of the patients in each group vomited. There were two aspirations, both in the non-contrast group. There were 50 abnormal scans in the contrast group and 55 in the no-contrast group. Nineteen contrast and 14 no-contrast patients were taken to OR.

Most interesting, there were 6 bowel injuries in the contrast group and one was not seen by CT. There were 3 bowel injuries in the no-contrast group and all were seen on CT. We found that there were always other signs of injury, such as mesenteric stranding or bubbles. 

Bottom line: Oral contrast is not necessary in acute blunt trauma patients undergoing CT of the abdomen. 

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