All posts by TheTraumaPro

Geriatric Week 1: How We Take Care Of Our Elders

Time for some philosophy again. A paper in Neurology released ahead of print confirms something I’m seeing more and more often. Specifically, hospitals can be bad for you, particularly if you are elderly.

The trauma population that we all see is aging with the overall population. Being older predisposes one to injuries that are more likely to require hospitalization. And unfortunately, being in the hospital can have adverse effects. I’m not just talking about the usual culprits such as medical errors or exposure to resistant bacteria.

The Chicago Health and Aging Project has been tracking a group of elders as they age, and has been making a number of interesting observations. Most recently, they have released information on a correlation between cognitive decline and hospitalization. They tracked nearly 1900 people, of whom 1335 ending up in the hospital for one reason or another (not just trauma). They found that there is a baseline rate of global cognitive decline with age (surprise!). Unfortunately, this rate of decline accelerated 2.4 times in the hospitalized group. Episodic memory scores declined 3.3 times faster, and executive function declined 1.7 times faster. And declines tended to be more pronounced in patients who had more severe illness, longer hospital stay, or advanced age.

There are some issues with the study. It is large, but it is a correlation study nonetheless. Are the effects due to something that happens in the hospital, or are they caused by something not evaluated by the study? It’s also not clear to me whether the declines noted are clinically significant in the daily lives of the people studied, or are just a number on some scale.

Bottom line: Some of the “benign” things that we do to patients in the hospital can have a big impact on their functional outcome. Always remember that they are more fragile than the young trauma patients we take care of. That extra fluid bolus, or dose of morphine, exposure to IV contrast, or noisy neighbor that keeps them from sleeping can make a real difference in how they do. Always consider that everything you do to them might kill them. Then seriously reconsider whether you really, really need to order it at all.

Reference: Cognitive decline after hospitalization in a community population of older persons. Neurology, 78(13):950-956, 2012.

Next Week: Trauma In The Elderly

All of next week, I’ll be writing about a topic that is becoming more and more important: geriatric trauma. Our population is aging, and the number of older patients being admitted to trauma centers is exploding.

Here are the topics to be covered:

  • How We Take Care Of Our Elders
  • Thoughts On Geriatric Trauma
  • Elderly Trauma And The Frailty Index
  • The Medical Orthopaedic Trauma Service
  • Falls In The Elderly: The Consequences
  • Effect Of an In-Hospital Falls Prevention Program

And please feel free to leave comments and suggest future topics!

Another Failure Of Shotgun Style Diagnostic Testing: The Trauma Incidentaloma

When our patients present with a problem, there is a time honored and well-defined sequence to help us come to a final diagnosis.

  • Take a detailed history
  • Examine the patient
  • Order pertinent diagnostic tests, if indicated
  • Then think about it a while

The first two items are a chip shot, and the trauma professional can gain a lot of information by spending a relatively short period of time doing these. And many times the diagnosis can be made without any further action.

However, diagnostic testing of all kinds has become so prevalent and easy to obtain that we rely on it a bit too much. And sometimes, we order it up in lieu of a thorough history and exam. If the clinician skimps on those steps, it’s much more difficult to narrow the list of differential diagnoses to a manageable number.

So what happens then? They use diagnostic tests as a crutch. Instead of being able to select a few focused tests to answer the questions, they essentially put an order sheet on the wall, fire off a shotgun, and order everything that’s been hit by the pellets.

Lots of tests, so they will definitely find the answer, right? Nope! There are two major problems here. First, the so-called signal to noise ratio is very low. There are so many results, that it is easy to overlook a pertinent positive among all the negatives.

But more significantly, there is always the possibility that there will be more than one positive. One of them might actually be the answer you were seeking. But what about the others? There are the trauma incidentalomas. Some may be truly positive, but there is always the possibility of a false positive. These are the most treacherous, because many trauma professionals then feel obligated to “do something about it.”

As we have found from multiple screening tests like PSA, PAP smear, and mammography, a significant number of patients may be harmed trying to further investigate what turns out to be nothing at all (artifact), or something completely benign. This includes not only harm from complications or unnecessary procedures, but months of anxiety the patient may suffer while the clinicians figure out what that thing inside them really is.

There are only a few studies on trauma incidentalomas available. One reviewed a series of almost 600 head CT scans in patients with TBI and found unexpected findings on 85%. About 90% were obviously benign. Unfortunately, it was not possible to follow these patients to find out how many of the remaining lesions turned out to be benign as well. But I would wager that most did.

Bottom line: I shouldn’t even have to say this, but do a good history and physical exam! If you need diagnostic studies, order only the one(s) that have the potential to make your final diagnosis. Don’t shotgun it. One very helpful tool is a well-designed practice guideline for commonly encountered clinical scenarios. This will limit the number of “other” findings you have to deal with. And finally, did I say to do a good history and physical exam?

Related posts:

Reference: Incidental cranial CT findings in head injury patients in a Nigerian tertiary hospital. J Emerg Trauma Shock 8(2):77-82, 2015.

Rest vs Physical Activity After Mild Pediatric Concussion: Which Is Better?

One of the most common recommendations after a child or young adult sustains a mild TBI is to rest. And even better, brain rest. I’ve written about that topic several times over the years.

But what about physical rest? There is a large body of literature documenting the numerous mental and physical benefits of exercise. Couldn’t they also apply after concussive injury to the brain? A study published recently tried to determine if physical activity or lack of it after mild TBI was helpful in reducing the incidence of post-concussive symptoms.

This was a planned analysis of prospectively collected data from nine research network hospital emergency departments in Canada. Children from age 5 through 17 were enrolled if they had received a concussion within 48 hours of the ED visit, as defined by the 2012 Zurich consensus. They were excluded if they had a positive head CT, GCS < 14, or pre-existing cognitive deficits.

Initial research data was collected during the ED visit, and followup phone calls were made by the research team at 7 and 28 days. They asked about self-reported level of physical activity on day 7, and post-concussive symptoms and their change over time on days 7 and 28.

Here are the factoids:

  • Of 3063 patients enrolled, 84% completed the ED assessment. 171 were excluded because they could not be contacted for the activity assessment on day 7.
  • Post-concussive symptoms were present in 30% of these children overall
  • 70% participated in physical activity during the first week: 32% light aerobic, 9% sport-specific, 6% non-contact drills, 4% full-contact practice, and 18% full competition (ignoring doctor’s orders?)
  • Overall, early activity was associated with a lower risk of post-concussive symptoms (25% vs 44%)
  • In patients who were symptomatic at day 7, symptoms were decreased at 28 days in patients who engaged in light aerobic activity, moderate activity, and even full-contact activity

Bottom line: This was a well designed study, but obviously with a number of limitations. Physical activity was self-reported, there may have been other factors that could not be controlled, and the study did not inquire about activity between days 7 and 28.

But this study appears to suggest that, like in most other areas, exercise is good. Even for the brain recovering from a concussion. Obviously, a really good randomized study would be the gold standard, but I doubt that will be done anytime soon. Trauma professionals may want to consider a cautious return to light to moderate activity as soon as the child feels well enough. But keep in mind that, in general, the onset of fatigue is a good indicator that it is time to stop activity and rest. And full contact should probably be avoided, especially because of the risk of re-injury.

Related posts:

Reference: Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA 316(23):2504-2514, 2016.

EAST 2017 #14: Long Term Consequences of Trauma: Why Aren’t We Looking?

I’m adding one more post to my EAST 2017 collection. This one struck me because it dovetails with another one I analyzed last week. After hearing both, something just clicked. The first was “When is mild TBI not so mild”, and opened my eyes to the fact that more TBI patients had ongoing problems than I imagined.

Now I just heard a presentation that looked at long term functional outcomes in patients with ISS > 9 at Brigham and Women’s Hospital. They identified patients in their trauma registry from 6 and 12 months prior to the study, and called these patients to administer several standard evaluation tools. Of 394 eligible patients, 27% could not be contacted, and 30% declined to participate, leaving 171 subjects. Half were 6 months out from their discharge, and half were a year  out.

The findings were very interesting. Here are the factoids:

  • 23% had a positive PTSD screen at 6 months, but this decreased to 16% at one year
  • A quarter of patients were still living with assistance that they did not need preinjury in both time periods
  • 20% of patients experienced a change in insurance
  • Half of the patients stopped working due to their injury, and this did not improve at one year
  • One in six were readmitted at some point for their injuries
  • The majority used some type of rehabilitation service (inpatient or outpatient) during their recovery

Bottom line: In my mind, this is a very big deal. All trauma centers collect a huge amount of data to monitor how things work while the patient is in the hospital. However, once discharged, they are on their own. We have no idea how they are doing, we have no mechanisms for finding out, and we have no systems in place to help if there are problems.

It is certainly simple enough to schedule a few phone calls at time intervals after discharge. We have tools and screening questions that we can ask. We can even include this information in the trauma registry and trend it. But then what?

This problem reaches beyond the trauma centers. Sure, we can make referrals for PTSD and rehab services. But what about the patient’s job, or their insurance? What if they don’t have insurance coverage or funds for needed services?

I believe that trauma centers should develop these processes and start collecting this information now. But we will also have to work with community and social service resources in order to marshal the services that our patients require. 

Reference: Routine inclusion of long-term functional and patient reported outcomes into trauma registries: can this be done? Paper #34, EAST 2017.