All posts by TheTraumaPro

Opioids In Trauma Care: Some Data

Yesterday I shared a TED Talk that outlined one person’s experience navigating the system (or lack thereof) for people trying to kick their addiction to medically prescribed narcotics. Today, I’ll share some new data that describes prescribing patterns and patient usage. This information was collected on patients after surgical procedures, not necessarily trauma, so this data may not be completely applicable. But it’s a start.

This paper is from the University of Vermont, and reviewed two datasets regarding opioid prescriptions. The first was a retrospective look at prescriptions written over a one year period after various surgical procedures in either an inpatient or outpatient setting at their center. This was used to design a patient telephone questionnaire containing questions about narcotic prescriptions and how much was used. The survey was administered about 1 week postop for patients having procedures over a 9 month period.

Here are the factoids:

  • Over 10,000 patients were identified in the retrospective arm of the study (!), of which 5100 were orthopedic procedures and 3100 were general surgery
  • 65% of patients were given only narcotic prescriptions on discharge, 24% were give no opioids, 3% were given only a Tramadol prescription, and 8% were given both
  • Residents wrote the vast majority of prescriptions at this academic medical center (63%), with 24% written by advanced practice providers and 13% by the attending surgeon
  • Drugs commonly prescribed in the retrospective data were oxycodone (44%, avg 30 pills), hydromorphone (31%, 25 pills), Tramadol (13%, 50 pills), and hydrocodone (8%, 20 pills)
  • There were considerable variations in prescribing patterns, drugs prescribed, and morphine equivalent doses provided across specialties
  • In the prospective data, the median amount of prescribed narcotic (in morphine equivalents) that was used was only 27%
  • Procedures associated with the highest amount of narcotic use were orthopedic in nature, particularly knee and shoulder operations

Bottom line: There is a huge amount of variability in prescribing patterns at one academic medical center, and this is probably true at most hospitals. There are a number of factors that contribute: the type of prescriber, local customary practices, type of surgery, and many more. Prescribers are not very experienced in predicting patient needs, and patients do not always do a good job communicating their needs to the clinicians.

In the next post, I’ll describe a suggested practice guideline that seeks to bring some sense to this complex topic.

Reference: Post-discharge opioid prescribing and use after common surgical procedures. J Am Coll Surg 226(6):1004-1013, 2018.

Opioids In Trauma Care: Food For Thought

Here’s something I ran across during my reading last week. In the “old days”, I used to encourage my trainees to be generous with pain medicine prescriptions for patients being discharged from the hospital. I would routinely send people home with 60, 75, or more pills. I got a hint of the folly of this just a few years ago when I underwent an outpatient procedure (biceps tendon repair).

The orthopedic surgeon prescribed 15 narcotic pain pills for me to take home. I scoffed at the low number, although I didn’t tell him that. But once I got home and the regional block wore off, how many do you think I took? Exactly one. I (safely) disposed of the rest. This prompted me to start rethinking our role in the opioid problem here in the US.

Tomorrow, I’ll write about a recently published paper and guideline for discharge opioid prescriptions. But today, watch the TED talk embedded below. It reveals the inadequacies within our health care system for those who, one way or another, have developed a dependence on these medications. It was an eye-opener for me.

The Handoff In Damage Control Surgery

Damage control is over 25 years old already! We continue to refine the techniques and closure techniques/devices, and have developed novel ways to speed closure of the abdominal wall in order to avoid pesky hernias. But the process itself is time intensive, and typically several days pass with regular returns to OR until closure is achieved.  This is one of the prime areas in which human error can occur, especially with modern service-style coverage of trauma patients.

In the old days, trauma patients were admitted by their surgeon, and that person provided their care nearly continuously until discharge. He or she rounded on them daily, took them back to the OR when needed, and then discharged them.

This is less practical (and desirable) in this day and age. And even if it seems possible, it’s not. No one can be on call 24 hours a day, and provide comprehensive care to every patient, around the clock. Many trauma programs have adopted a “service model”, where patients are admitted to a defined care team and managed by them. The team is led by a surgeon, but that person may change on a weekly (or in some cases nearly daily) basis. I call this the “interchangeable head” model, and to make it work there must be excellent handoffs during any leadership change.

In some cases, a patient may undergo a damage control procedure by one surgeon, but another must do the takeback and possibly the definitive closure. In this case, the handoff is critical! It is paramount that the next surgeon know everything about the first case so that they can perform the correct procedure.

How can this be accomplished? Here are some tips:

  • Do not rely on the medical record and previous operative note. It may not be available, and there is usually some loss of information in recording it anyway. Don’t believe it.
  • Ideally, meet face to face with the previous surgeon(s). Get the blow by blow description of exactly everything that was done and how. Also discuss what still needs to be done, and when. Try to maintain a uniform philosophy of patient care across surgeons.
  • If face to face is not possible, a telephone call is acceptable. The discussion is exactly the same.
  • If the surgery occurred at an outside hospital and was then transferred, you must call the initial surgeon to have this discussion before going to the OR!
  • If something unexpected is encountered during the case, make sure you have contact information so you can call during the case.

Applying these concepts will decrease the possibility of error, as well as the likelihood of any iatrogenic harm to these complex patients.

ED Thoracotomy Survey: Read The Answers! (Rest of the World)

Last time, I posted summary info for ED thoracotomy on US trauma centers. Here’s a rundown of the answers provided by international respondents. A few duplicates from the same hospitals have been merged into single answers for them. The total number of international centers for the tables below is now 43.

Level of trauma center (or equivalent)

Level I 22
Level II 8
Level III 6
No level 7

 

How many ED thoracotomies are performed per year at your hospital?

A few per year (<6) 30
About every month (6-15) 6
A couple of times a month (16-30)4 4
About every week (31-52) 2
Not specified 1

 

What type of trauma do you perform ED thoracotomy for?

Both blunt and penetrating 22
Penetrating 17
Blunt 4

 

Do you use a practice guideline for ED thoracotomy?

Yes 17
No 16
I’m not sure 10

 

Do you use REBOA in your ED?

No 32
Yes 9
I’m not sure 2

 

And now for the questions you’ve been waiting for!

Who could perform ED thoracotomy at your hospital? (n=149)

Surgeon 39
Emergency physician 25
Surgical resident / fellow 15
Emergency medicine resident 7
Intensivist 1
ED intern / medical officer 1
No one 1

 

Who usually performs ED thoracotomy at your hospital? (n=149)

Surgeon 32
Emergency physician 15
Surgical resident / fellow 9
Emergency medicine resident 1
Thoracic surgeon on call 1
Trauma team leader 1
Never done one 1