Monthly Archives: October 2015

General

10 Things That Will Get You Sued – Part 2

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#3. You are responsible for the conduct of your staff

If the people who work for you treat patients
poorly, you may be responsible. It is important that your staff have bedside
manner at least as good as yours.

#4. Avoiding
your patients

Some of your patients may need to contact you,
either while in the hospital or while at home. Don’t appear to be inaccessible.
This is an extension of your bedside manner. Return phone calls or messages
promptly, or have one of your staff do so. Make time to meet with patient
families while in the hospital. Remember, you
deal with trauma all the time; this is probably the first time they have and it
is extremely stressful.

#5. Ordering
a test without checking the result

I presume that if you order a test, you are
interested in the result. And hopefully it will make some difference in patient
care. If not, don’t order it. But if you
do order a test, always check the
result. If a critical result is found, don’t assume that “someone” will
tell you about it. You are
responsible for checking it and dealing with any subsequent orders or followup
that is needed.

#6. “What
we have here is a failure to communicate” – part 2

Most of the time, our patients have primary care
providers somewhere. Make it a point to identify them and keep them in the
loop. Provide, at a minimum, a copy of the discharge summary from the hospital
or emergency department. If new therapies of any kind are started, make sure
they are aware. And if an “incidentaloma” is found (a new medical condition
found on lab tests or imaging studies), followup with the primary care provider
to make sure that they are aware of it so they can take over responsibility for
further diagnosis or treatment.

See part 3 of this series tomorrow!

General

10 Things That Will Get You Sued – Part 1

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Many
trauma professionals believe that they can only be sued if they make a medical
error and some harm occurs. Unfortunately, this is not entirely true. Yes,
this is one obvious way to spark a suit or claim.

Unfortunately, it goes beyond that. Your patient
may sue you if they even believe that
they were harmed in some way, or think that something untoward happened while
you were providing care. Here are the top 10 reasons for getting sued and my
thoughts on each (in no particular order).

#1. “What
we have here is a failure to communicate”

Your interpersonal skills are at least as
important as your clinical skills! You may be a clinical prodigy, but if you
are an asshole at the bedside, your patients will never appreciate your skills. You must be able to listen and
empathize with your patient. Sit down, look at them eye to eye. Listen
attentively. Don’t appear to be in a rush to get out of the room. You’d be
surprised at how much more valuable information you will get and the
relationship you create.

#2. “Work
not documented is work not done” (This is my quote and it’s one of my favorites.)

Accurate, complete, timely, and legible
documentation is a must!
The legibility problem is fading with the widespread use of electronic health
records (EHR, although this is creating new problems). Documentation, or lack
thereof, will not get you sued by itself. However, if you are involved in a suit or claim
and your care is scrutinized, poor or missing documentation will make it
impossible to plausibly contend that you did what you say you did. 

It’s
critical that you document every encounter thoroughly enough to be able to
reconstruct what you were thinking and what you did. And providing a date
and time is absolutely critical. This is especially important when the EHR
timestamps everything you enter. Frequently, you will be documenting something somewhat
after the fact. Always make sure that it’s not too far after the fact. Document as promptly as you can, and
include the time that you were actually providing the service. 

And
never go back and try to “correct” your documentation, especially if the chart
is being requested for inclusion in a suit or claim. If you believe there is an error, create an addendum and explain why the correction
is necessary. If a suit or claim has been started, do not touch or open the
chart without advice from your legal counsel.

Stay tuned for Part 2 tomorrow!

General

Giving Vitamin D After Fracture

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The role of Vitamin D in fracture healing is well known. So, of course, trauma professionals have tried to promote Vitamin D

supplementation to counteract the effects of osteoporosis. A meta-analysis of of 12 papers on the topic relating to hip and other non-vertebral fractures showed that there was roughly a 25% risk reduction for any non-vertebral fractures in patients taking 700-800 U of Vitamin D supplements daily.

Sounds good. So what about taking Vitamin D after a fracture occurs? Seems like it should promote healing, right? A very recent meta-analysis that is awaiting publication looked at this very question.

Unfortunately, there was a tremendous variability in the interventions, outcomes, and measures of variance. All the authors could do was summarize individual papers, and a true meta-analysis could not be performed.

Here are the factoids:

  •  81 papers made the cut for final review
  • A whopping 70% of the population with fractures had low Vitamin D levels
  • Vitamin D supplementation in hospital and after discharge did increase serum levels
  • Only one study, a meeting abstract which has still not seen the light of day in a journal, suggested a trend toward less malunions following a single loading dose of Vitamin D

Bottom line: Vitamin D is a great idea for people who are known to have, or are at risk for, osteoporosis and fractures. It definitely toughens up the bones and lowers the risk of fracture. However, the utility of giving it after a fall has not been shown. Of the 81 papers reviewed, none showed a significant impact on fracture healing. The only good thing is that Vitamin D supplements are cheap. Giving them may make us think that we are helping our patient heal, but it’s not. 

Related posts:

References:  

  • What is the role of vitamin D supplementation in acute fracture patients? A systematic review and meta-analysis of the prevalence of hypovitaminosis D and supplementation efficacy. J Orthopaedic Trauma epub Sep 22 2015.

  • Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 293(18):2257-2264, 2005.

General

The ICU Bounce Back

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We’ve all experienced it. A seriously injured trauma patient is admitted to the ICU and begins the process of recovery. Everything looks well, and after a few days they are transferred to a ward bed. But then they languish, never really doing what we expect. Finally (and usually in the middle of the night), they begin to look bad enough where we have to transfer them back to the ICU.

What’s the problem here? A failure of the ICU team? Did we all miss something? Is there any way we can avoid this problem? The major issue is that these “bounce backs” tend to do poorly compared to patients who successfully stay in their ward bed. Estimates are that mortality for patients successfully and finally discharged from the ICU range from 4-8%, whereas the mortality in bounce back patients is 20-40%!

Researchers at the Medical University of South Carolina in Charleston looked at the characteristics that defined the bounce back patient. They looked at nearly 2000 patients discharged from the trauma ICU and analyzed the variables that predicted an unplanned bounce back. They noted the following interesting findings:

  • More than two thirds of bounce backs occurred within 3 days
  • Males, patients with an initial GCS < 9, transfer during the day shift, and the presence of comorobidities
  • More comorbidities was associated with a higher chance of bounce back
  • Mortality in the bounce back group was 20%
  • The most common factors causing bounce back were respiratory failure or bleeding

Bottom line: This is an intriguing single-institution study that supports my own personal observations. Fewer bounce backs occur at night because staffing tends to be lower and there is more resistance to transfers out of the ICU to make room. Both the ICU team and the ward team need to scrutinize every transfer carefully. Significant head injury or the presence of medical comorbidities should trigger a careful assessment to make sure that the transfer is appropriate. Otherwise, your patient may be placed in unnecessary jeopardy.

Related posts:

Reference: Intensive care unit bounce back in trauma patients: An analysis of unplanned returns to the intensive care unit. J Trauma 74(6):1528-1533, 2013.

General

The Robert Jones Dressing

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The Robert Jones dressing is a thick, padded bandage classically applied to the thigh and leg. It is thought to reduce swelling by applying even pressure to the extremity, which in turn should promote healing. And since it is a soft dressing, as opposed to a cast, there is less chance of developing skin breakdown from direct pressure. Here’s a compression-type dressing described in 1937 using stockinette, cotton wool, and elastic cloth, although it was not attributed to Jones at that point.

Charnley provided a detailed description of the bandage in 1950, and was the first to refer to Jones.

Interestingly, Robert Jones never really referred to the dressing by name. There were references to a “pressure crepe bandage over copious wool dressing” in his operative logs, but it wasn’t until much later that his name became associated with it. Because of this, the composition of the bandage has varied greatly over time.

But who was Robert Jones? We in the States are fairly ignorant, but my UK readers are very familiar. Jones was a British surgeon who practiced through the late 1800s and past the end of World War I. He learned about fractures from his uncle, and became one of the few surgeons of the time to be interested in fracture care. Until then, orthopaedics was focused primarily on correcting deformities in children. He received his FRCS in 1889. After being appointed Surgeon-Superintendent of the Manchester Ship Canal, he established the first comprehensive accident service in the world to take care of injured workers. He founded the British Orthopaedic Society in 1894, and introduced the concept of military orthopaedic hospitals during World War I. His innovations led to significant decreases in morbidity and mortality from fractures in the war, particularly of the femur.

And does his eponymous dressing actually work? There has been little research in this area. There is one study that I have found that actually measured compartment pressures to see if the loss of edema from compression caused a noticeable pressure decrease. Here are the factoids:

  • This was a very small prospective study from 1986 of 9 patients (!) who had just undergone knee arthroplasty
  • Slit catheters were placed into the compartment 10 cm below the knee joint (but they didn’t say which compartment)
  • Thick cotton-wool from a roll was applied over the surgical dressings twice, each with a thickness of two inches. An elastic bandage was then applied snugly.
  • Much to the researchers’ surprise, compartment pressures did not fall as expected over time. They were basically constant until the dressing was removed. Then the pressures fell significantly.

Bottom line: Robert Jones’ fame is well deserved. However, his dressing (which he did not name, and may not even be what he used), did not have the pressure-reducing effect on an injured limb that surgeons thought. No studies on edema and healing have been done. It’s basically a fluffy dressing. However, that is a good thing. It keeps the leg padded, protecting the skin, and immobilized. It’s like a very well padded cast, without the risk of skin breakdown. And because of its simplicity, it will probably be used for quite some time to come.

Related posts:

References:

  • The Robert Jones bandage. JBJS 68B(5):776-779, 1986.
  • The treatment of fracture without plaster of Paris. Closed Treatment of Common Fractures, E&S Livingstone 1950, pg 28-29.
  • Handbook of Orthopaedic Surgery. CV Mosby 1937, pg 418.