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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. 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.

Tune in for Part 2 in my next post!

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Extremity

What A MESS! Part 2

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The trauma season is always officially open. And unfortunately, our patients can sustain mangled extremities in any number of ways. In days of old, management was simple: take it off. But we’ve become wiser over the years and are now able to salvage a good number of these threatened limbs. The Mangled Extremity Severity Score (MESS) has helped greatly with this. 

As I mentioned yesterday, it’s beginnings were humble, almost looking like guesswork on the part of the authors. But this system has withstood the test of time.

There are four components to MESS: limb ischemia, patient age, presence of shock, and mechanism of injury. Each component is assigned an integer value depending on severity. The possible values range from 1 to 14. Here’s the breakdown of each component:

Ischemia

  • +1 Reduced pulse but normal perfusion
  • +2 Pulseless, paresthetic, reduced capillary refill
  • +3 Cool, paralyzed, insensate
  • Add 3 points if limb ischemia has been present more than 6 hours

Age

  • +0   <30 years
  • +1   30-50 years
  • +2   >50 years

Shock

  • +0 SBP >90 consistently
  • +1 Transient hypotension
  • +2 Persistent hypotension

Mechanism (kinetic energy)

  • +1 Low (stab, gunshot, simple fracture)
  • +2 Medium (dislocation, open or multiple fractures)
  • +3 High (high speed MVC, rifle)
  • +4 Very high (high energy trauma with gross contamination)

Per the original study, values of 7 or greater predict low salvageability. However, with advancing technology, drugs, and operative techniques, the threshold has been creeping higher. But not that much higher, probably 8 or so.

Bottom line: Use the MESS score as one tool in your armamentarium to help address mangled extremities. But remember, it is not the final answer. In the OR, confer with your orthopedic and vascular colleagues. Decide if immediate amputation is necessary, or whether a second look in a day or two is in order. Use MESS as a tiebreaker. But remember, don’t let your desire to save the extremity jeopardize your patient’s life (rhabdomyolysis, renal failure, acidosis). If systemic signs begin to occur, cut your (and their) losses and amputate!

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Extremity

What A MESS! Part 1

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The Mangled Extremity Severity Score (MESS) is now 25 years old, and it still serves us fairly well. This simple system helps predict salvageability of mangled extremities. Obviously, the acronym was chosen to help describe the clinical problem.

The system was originated at the Harborview Medical Center in Seattle. The development was not very scientific; the authors put their heads together and made a list of the four things that they observed predicted limb salvage:

  • Degree of skeletal and soft tissue injury
  • Presence of limb ischemia
  • Presence of shock
  • Age

The system was used retrospectively in a group of 25 patients(!) and the authors found a nice breakpoint at 7. Any mangled extremities with a MESS of 7 or more required amputation. They then applied this to 26 patients prospectively(!) and got the same result.

As you can see, the numbers were small, and there was no followup information. Nevertheless, MESS still stands today, and the critical MESS score has not changed much. It has been validated by a number of other studies during the past 20 years. It is conceivable that the critical score will slowly creep upward with advancements in flap coverage and surgical technique, but it hasn’t done so yet.

Tomorrow, I’ll show you how to calculate the MESS score, and give some tips on how to use it.

Reference: Objective Criteria Accurately Predict Amputation Following Lower Extremity Trauma. Johansen, et al. J Trauma 30(5): 568, 1990.

Extremity, Tips

Practical Tips: Transferring The Mangled Extremity

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Managing the mangled extremity is both challenging and intense. There is always pressure to do all we can to save that threatened limb. But as you know, different levels of trauma centers have different capabilities and specialists that are needed to fully manage these injuries.

Level I centers have a comprehensive set of specialists to deal with the managed extremity, including trauma surgeons, vascular surgeons, orthopedic surgeons comfortable with complex injury, plastic surgeons, and interventional radiologists. The expectation is that a mangled extremity can be completely managed at such a center.

Level III centers have much more limited resources, and may only have a trauma surgeon to perform the initial evaluation. Definitive management can only occur after transfer to a Level I center.

Level II centers often find themselves in a kind of limbo. They have most of the specialties required, but those specialists may have varying comfort levels regarding addressing complex injuries. Some Level II centers may be able to keep these patients, but many will find that they need to transfer to their upstream Level I partner.

What do transferring trauma centers need to do before actually moving the patient? Here are some practical tips.

  • Evaluate quickly. The bottom line is to try to preserve function, so time is of the essence. Do a thorough evaluation of the anatomy, as well as vascular and neurologic status. These are the major determinants of salvageability.
  • Don’t ignore the rest of the patient. Make sure that injuries more critical than the extremity are identified and addressed. See the “Dang Factor!” below.
  • Make a decision. Now. Decide whether you need to transfer the patient based on your knowledge of your consultants’ skill levels and comfort.
  • Once you decide you will transfer, do no further imaging. It’s not going to change anything you do, and may not be very helpful to the receiving center.
  • Give IV antibiotics and the life-saving tetanus shot early.
  • Optimize salvageability. Do what you can to keep tissue healthy during the transfer. You must take transfer time into account for this! If you are sending your patient across town, just do it quickly. However, if he or she must travel long distance, there are a few more things to consider:
    • Try removing the tourniquet (if any). You’d be surprised at how many times the bleeding has stopped already. Or maybe wasn’t needed in the first place.
    • Selectively try to control bleeding if possible. Carefully ligate small vessels if you can. Don’t clamp and tie large masses of tissue.
    • Consider a vascular shunt. If there is an obvious large vessel injury, and if you have a trauma or vascular surgeon who is comfortable with inserting a vascular shunt, do it prior to transfer. This will increase the likelihood of salvage in long-distance transfers. But don’t waste a lot of time doing this! If you can’t get it done within about 30 minutes or so, don’t delay the transfer.
    • Quickly rinse off the area. Try to minimize the time that noxious stuff (dirt, gasoline, etc) is in contact with the tissues.
    • Splint well. You’ll need to be creative. But you don’t want additional tissue injury due to the extremity just flopping around.
  • Inquire about followup. Find out how the patient did, and discuss anything you could have done differently with the receiving center. As always, performance improvement is important!

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General

IVC Filters: Another Nail In The Coffin?

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IVC filter insertion has been one of our tools for preventing pulmonary embolism for decades. Or so we thought. Its popularity has swung back and forth over the years, and has been in the waning stage now quite some time. This pendulum like motion offers an opportunity to study effectiveness when coupled with some of the large datasets that are now available to us.

IVC filters have been used in two ways: prophylactically in patients at high risk for pulmonary embolism (PE) who cannot be anticoagulated for some reason, and therapeutically once a patient has already suffered one. Over the years, guidelines have changed, and have frequently been in conflict. Currently, the American College of Chest Physicians does not recommend IVC filters in trauma patients, while the Eastern Association for the Surgery of Trauma promote their use in certain subsets.

A Pennsylvania group performed a large, retrospective review of three databases, the  Pennsylvania Trauma Outcome Study (462K patients), the National Trauma Data Bank (5.8M patients), and the National Inpatient Sample. All were patients with an emergent trauma-related admission.

Here are the most interesting factoids:

  • About 2% of all patients underwent IVC filter insertion, and 94% were inserted prophylactically
  • About 90% of patients with a prophylactic filter had at least one predictor for PE, which means that the remaining 10% had none (!)
  • Conversely, about 86% of patients who developed a PE had at least one risk factor, meaning that 14% had no recognized risk factors (!!)
  • The use of IVC filters peaked in 2006-2008 at 2-4%, then falling steadily over the following 5-7 years to less than 1%
  • PE rates peaked in 2008, then declined by 30% in the PTOS sample and stayed steady in the NTDB

Bottom line: The use of IVC filters peaked in 2008 and has been in decline since then. But interestingly, the rates of PE and fatal PE have been steady to declining, depending on the data set. Obviously, there are always some shortcomings for studies like this. Remember, IVC filters are intended to prevent fatal PE. It is possible that some fatal PEs were not identified in these databases. Furthermore, it was not possible to obtain any information on the use of chemical prophylaxis in these patients. 

Overall, there has been no increase in PE and fatal PE rates over the time period that IVC filter usage has been decreasing. This suggests that these devices have not had their intended effect. Trauma professionals need to very seriously consider the specific indications in any patient they are considering for insertion. They may not have the protective effect you think.

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Reference: Vena Cava Filter Use in Trauma and Rates of Pulmonary Embolism, 2003-2015. JAMA Surg 152(8):724-732, 2017.