How To Remove A Chest Tube
The cost of care in a trauma center is high. When anything is expensive, it is natural to wonder about its cost-effectiveness. A group of biostatisticians recently looked at the treatment costs and cost-effectiveness of treating trauma patients in a trauma center vs an nontrauma hospital. They were very comprehensive in looking at costs, including costs for transportation, treatment at a transferring hospital, rehospitalization for acute care if needed, inpatient rehab, stays in longterm care or skilled nursing care facilities, outpatient care and informal care given by family members.
Treatment at a trauma center saved 3.4 lives per 100 patients treated. The overall added cost for treatment at a trauma center was about $36,000 per life year gained. However, in order to gauge cost-effectiveness we need to know what a year of life is worth. As you can imagine, this is tough to figure out. A number of researchers have looked at this, and it typically ranges from $50,000 to $200,000 per year. Thus, trauma center care is overall cost-effective.
The data was more closely analyzed, and it appears that the cost-effectiveness is greater for patients with more severe injuries. Unfortunately, cost-effectiveness is not as clear for patients who are 55 years or older.
The bottom line: Trauma is a leading cause of death in this country. The concept of treating more severely injured patients at trauma centers is both effective and cost-effective. Trauma systems need to be fine-tuned so that they get the right patient to the right hospital and so care for elderly patients continue to improve.
Reference: Nathens et al. The Value of Trauma Care. J Trauma 69(1):1-10, 2010.
EMS providers are the trauma professional’s eyes and ears when providing transportation from the scene of an accident. We rely on their assessment of the mechanism of injury and the amount of blood lost. We tend to believe in the accuracy of those assessments.
A study was carried out that tested EMS personnel on their ability to accurately estimate specific amounts of blood that were left at a simulated accident scene. The blood volumes tested were 500cc, 1000cc, 1500cc and 2100cc. A total of 92 professionals participated, and there was an even split into basic EMTs (34%), intermediate/critical care EMTs (33%) and paramedics (31%). Experience levels were as follows: 0-5 years 43%, 6-10 years 30%, >10 years 31%.
The results were as follows:
- 87% underestimated the quantity of blood
- 9% overestimated
- 4% guessed the exact amount
- Experience or credentialing level did not matter
Only 8% of the subjects were within 20% of the actual volume, and an additional 19% were within 50%. In general, most medics underestimated the amount of blood lost, and their guesses were worse with higher volumes. The median guess for the 2100cc loss group was only 700cc!
The bottom line: Visual estimates of blood loss are extremely inaccurate, and are most likely underestimates. Physicians in the ED should rely on exam and physiology to help determine the amount of blood loss. For safe measure, multiply the reported blood loss of the EMT or paramedic by 2 or 3 to get a realistic number.
Reference: Patton et al. Accuracy of Estimation of External Blood Loss by EMS Personnel. J Trauma 50(5), 914, 2001.
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.
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.