Trauma services tend to have fairly rapid patient turnover. Many of the patients that are seen have injuries that are easily managed, leading to discharge within one to two days. On the flip side, some have such severe injuries that they may be in the hospital for weeks or even months. But regardless of injury, there are always a few who we just can’t seem to discharge at all. Why does this happen?
The trauma program at the Massachusetts General Hospital looked at 5 years worth of admission data on adult patients. They looked at the usual hospital demographics, billing information, hospital financial information, and discharge disposition. The ultimate goal was to identify patients who had an excessively prolonged hospitalization (defined as 2 standard deviations above the average length of stay for the associated Diagnosis Related Group) and why.
Here are the factoids:
- 155 of 3237 admitted patients (5%) had an extended stay. The total number of admits seems weird, since this would average out to only 650 admissions per year to this busy hospital.
- The usual injury severity demographics were similar.
- Extended stay patients tended to be older, sustained blunt trauma, were Medicare or no-pay patients, and were discharged to facilities other than home.
- Length of stay was 3 times longer than the usual patients
- Hospital cost was 3 times higher, and the hospital lost a lot of money on them.
- In-hospital mortality was lower for these patients (?!).
- The biggest factors delaying discharge were transfer to a rehab or other post-acute care facility, and self-pay or Medicare pay status.
Bottom line: Extended stay in the hospital when not medically indicated is a bad thing, and it’s a system problem. The chance of complications is always present, including deep venous thrombosis, exposure to resistant organisms, UTI, pneumonia, and medication error, just to name a few. And it’s generally bad for the hospital’s financial health, as well. If you are experiencing this at your center, carefully analyze the reasons why it typically occurs. Then work proactively to address them.
- Identify potential problem discharge patients on their first day in the hospital
- Develop special arrangements with post-discharge facilities.
- Hire skilled (and aggressive) social workers
- Don’t give up!
Reference: Excessively long hospital stays after trauma are not related to the severity of illness. JAMA Surg 148(10):956-961, 2013.
We’ve been pondering this question for nearly 30 years. In 1983, trauma surgeons at UCLA looked at a number of devices available at that time and tested them on normal volunteers. They measured neck motion to see which was “best."
Here’s what they found:
- Soft collar – In general, this decreased rotation by 8 degrees but insignificantly protected against flexion and extension. Basically, this keeps your neck warm and little else.
- Hard collars – A variety of collars available in that era were tested. They all allowed about 8% flexion, 18% lateral movement, and 2% rotation. The Philadelphia collar allowed the least extension.
- Sandbags and tape – Surprisingly, this was the best. It allowed no flexion and only a few percent movement in any other direction.
The Mayo clinic compared four specific hard collars in 2007 (Miami J, Miami J with Occian back, Aspen, Philadelphia). They found that the Miami J and Philadelphia collars reduced neck movement the best. The Miami J with or without the Occian back provided the best relief from pressure. The Aspen allowed more movement in all axes.
And finally, the halo vest is the gold standard. These tend to be used rarely and in very special circumstances.
- For EMS: Rigid collar per your protocol is the standard. In a pinch you can use good old tape and sandbags with excellent results.
- For physicians: The Miami J provides the most limitation of movement. If the collar will be needed for more than a short time, consider the well-padded Occian back Miami J (see below).
- Efficacy of cervical spine immobilization methods. J Trauma 23(6):461-465, 1983.
- Range-of-motion restriction and craniofacial tissue-interface pressure from four cervical collars. J Trauma 63(5):1120, 1126, 2007.
A lot has been written about the hazards of distracted driving. Now, there is new information about the impact of distraction on police officers! A public safety administration class at St. Mary’s University here in Minnesota analyzed 378 crashes involving police cars from 2006 to 2010. The results are intriguing!
Key findings included:
- Most crashes occurred during non-emergency responses
- Crashes occurring during emergency responses were the most expensive
- Distracted driving caused 14% of all crashes
- Half of distracted driving crashes were due to the use of squad car computers
- Average insurance claim was $3,000 per crash. However, if the crash was due to distracted driving it doubled to $6,000. If the crash was due to squad car computer distraction the average cost was $10,000!
This study is interesting, but it’s only a partial snapshot of this type of crash in one state. It did not include some of the larger police departments, such as St. Paul and Minneapolis.
Bottom line: It’s safe to assume that distracted driving is just as dangerous to police (and prehospital providers, too). And with growing dependence on advanced technology for law enforcement, this problem is just going to get worse. It is imperative that everything be done to improve safety for our law enforcement colleagues. Potential solutions include training to increase awareness of distractions within the car, simulator testing of driving while using cockpit technology, and ergonomic studies to maximize field of view from within the car.
Medicine is full of conditions with eponyms. Trauma is no exception. There’s the Mattox maneuver and the Cushing response, to name two. Many times, the name is just a kind of vanity plate for the discoverer of the condition. But in the case of the LisFranc injury (or fracture), it makes some sense. This injury is tough to describe in a sentence or two, let alone a few words.
Jacques LisFranc de St. Martin was a French surgeon and gynecologist (!) who described this condition in about 1815. It entails the fracture of the heads of the metatarsal bones and possible dislocation from the tarsals (the cuboid, navicular, and three cuneiform bones). This area is known as the LisFranc joint complex.
The injury can involve any or all of the metatarsals. The typical mechanism applies high energy across the midfoot, which can often be seen in head-on motor vehicle crashes. Crush injury to the proximal foot can also do this, such as running the foot over with a car. Occasionally, this injury pattern is produced with lower energy during sports play. In this case, the top of the foot is typically contacting the ground, plantar flexing it. At the same time, another player steps on the heel, grinding the foot into the ground (ouch). Interestingly, LisFranc did not describe the injury pattern or mechanism. His name is associated with the joint complex, and it is an injury to his joint complex.
Most of the time, the injury is obvious. There is usually notable pain and swelling of the foot. X-ray findings are generally not subtle. However, lower energy mechanisms may not cause much displacement, and initial imaging may not show the injury. If your patient starts to complain of pain in the midfoot when they begin to ambulate, think of LisFranc.
Treatment depends on the degree of displacement and the amount of disruption of the tarso-metatarsal joints. If minimal, a trial of nonoperative, non-weight bearing may be sufficient. But frequently, surgical reconstruction is required.
For those of you with poor internet connections, I’ve created a downloadable version of today’s Mechanism of Injury For Prehospital Providers talk.
Click here to download