All posts by TheTraumaPro

Nursing Malpractice: The Basics – Part 1

Back in the old, old days, there was really no such thing as nursing malpractice. Nurses had little true responsibility, and liability largely fell to the treating physicians. But as nursing responsibilities have grown, they have become an integral part of the assessment, planning, and management of their patients.

As all trauma professionals know, our work is very complex. And unfortunately, our understanding of how the human body works and responds to injury is still incomplete. So unfortunately, undesirable things happen from time to time.

But does every little adverse event or complication mean that someone is at fault? Or that they can/should be sued? Fortunately, the answer is no.

The law is complex, at least to professionals outside the legal field. Following are the basics of malpractice as it relates to nurses.

There are four elements that must be present for a malpractice case to be brought forward:

  1. The nurse must have established a nurse-patient relationship. Documentation provided by the nurse or other providers in the medical record must demonstrate that they were in some way involved in care of the patient.
  2. A scope of duty must be established within the relationship. For example, an ICU nurse will have duties relating to examining the patient, recording vital signs, reporting significant events to physicians, etc. The exact duties may vary somewhat geographically and even between individual hospitals. Written policies help to clarify some of these duties, but often, experts are required to testify to what the usual standards of care are when not covered by policy.
  3. There must be a departure from what is called “good and accepted practice.” The definition of this leaves a lot of wiggle room. It is defined as the care that an ordinarily prudent nurse would have provided in the given situation. It does not need to be the optimum or best care. And if there is more than one approved choice, a nurse is not negligent if they choose either of them, even if it later turns out to be a poorer choice.
  4. Finally, there must be a cause-effect relationship between the nurse’s action and the patient’s alleged injury. This linkage must be more than a possibility, it must be highly probable. For example, wound infections occur after a given percentage of operations, and it varies based on the wound classification. It’s a tough sell to bring suit for improper dressing care in a grossly contaminated wound that is likely to become infected anyway. Typically, expert witnesses must attest to the fact that the patient was, more likely than not, harmed by the nurse’s action or inaction.

Stay tuned tomorrow for part 2!

Flying Or Diving After Traumatic Pneumothorax: Part 2

Yesterday, I wrote about the accepted management of and delay in flying due to traumatic pneumothorax. I republished the post because of the very recent acceptance for publication of a paper from Oregon Health Science University in Portland. The authors specifically tried to assess timing of chest tube removal and long-distance flight, and to measure the risk of pneumothorax recurrence or other complications.

The authors performed a retrospective review of a series of military patients who had sustained chest injuries that were treated with chest tubes over a 5 year period from 2008 to 2012. After tube removal and a pneumothorax-free period of at least 24 hours (by chest x-ray), the patients were then transported by air from the military theater back to the United States.

Here are the factoids:

  • Of 517 patients screened in the military trauma registry database, only 73 were available for study after applying exclusion criteria
  • Subjects were predominantly young and male, as one would expect from the injured military population, and 74% were injured by a penetrating mechanism
  • Median time that the chest tube was in place was 4 days, and median time from tube removal to flight was 2.5 days
  • All patients had post-flight documentation available for review, but only half (37) had in-flight documentation available
  • Nearly half (40%) had positive pressure ventilation in place during the flight
  • Five patients had “in-flight medical concerns” (4 were ventilated), but none were related to the pneumothorax. The four ventilated patients had ventilator issues, the non-vented patient had “self-limited discomfort without evidence of respiratory distress.”
  • None of the subjects developed a recurrent pneumothorax, either post-flight or over the following 30 days

The authors conclude that air travel after tube removal and a 24-72 hour observation period “appears safe.”

Bottom line: Not so fast! This is yet another small, retrospective study making grand claims. The study group is a very unique population: healthy, fit young men with penetrating injury. Your average civilian trauma patient is older, less healthy, and usually has a blunt mechanism with multiple rib fractures. In-flight documentation was not available in half of the cases. And a full medical team was present on the aircraft had a problem actually occurred.

Contrast this with a civilian patient on a commercial aircraft with very limited medical equipment and expertise on board. What could go wrong? I definitely do not recommend changing our practice on these patients yet based on this one paper. Until we have better guidance (more good papers) stick to the usual wait time to ensure a safe flight for your patient.

Reference: Trauma patients are safe to fly 72 hours after tube thoracostomy removal. J Trauma, published ahead of print, May 18 2018.

Flying Or Diving After Traumatic Pneumothorax: Part 1

Today, I’m dusting off an old post on flying and diving after pneumothorax. This shows the thinking up until last year. Tomorrow, I’ll write about a new paper that suggests that we can shorten the “no-fly” time considerably.

Hint: no changes to the diving recommendations. One pneumothorax is likely to ground you forever.

Patients who have sustained a traumatic pneumothorax occasionally ask how soon they can fly in an airplane or scuba dive after they are discharged. What’s the right answer?

The basic problem has to do with Boyle’s Law (remember that from high school?). The volume of a gas varies inversely with the barometric pressure. So the lower the pressure, the larger a volume of gas becomes. Most of us hang out pretty close to sea level, so this is not an issue. But for flyers or divers, it may be.

Flying

Helicopters typically fly only one to two thousand feet above the ground, so the air pressure is about the same as standing on the earth. However, flying in a commercial airliner is different. Even though the aircraft may cruise at 30,000+ feet, the inside of the cabin remains considerably lower though not at sea level. Typically, the cabin altitude goes up to about 8,000 to 9,000 feet. Using Boyle’s law, any volume of gas (say, a pneumothorax in your chest), will increase by about a third on a commercial flight.

The physiologic effect of this increase depends upon the patient. If they are young and fit, they may never know anything is happening. But if they are elderly and/or have a limited pulmonary reserve, it may compromise enough lung function to make them symptomatic. And having a medical problem in an aluminum tube at 30,000 feet is never good.

Commercial guidelines for travel after pneumothorax range from 2-6 weeks. The Aerospace Medical Association published guidelines that state that 2-3 weeks is acceptable. The Orlando Regional Medical Center reviewed the literature and devised a practice guideline that has a single Level 2 recommendation that commercial air travel is safe 2 weeks after resolution of the pneumothorax, and that a chest x-ray should be obtained immediately prior to travel to confirm resolution.

Diving

Diving would seem to be pretty safe, right? Any pneumothorax would just shrink while the diver was at depth, then re-expand to the original size when he or she surfaces, right?

Not so fast. You are forgetting why the pneumothorax was there in the first place. The lung was injured, most likely via tearing it, penetration by something sharp, or popping a bleb. If the injured area has not completely healed, then air may begin to escape through it again. And since the air used in scuba diving is delivered under pressure, this could result in a tension pneumothorax.  This is disastrous underwater!

Most injuries leading to pneumothorax heal completely. However, if there are bone spicules stuck in the lung or more complicated parenchymal injuries from penetrating injury, they may never completely heal. This makes the diver susceptible to a tension pneumothorax anytime they use their regulator.

Bottom line: Most patients can safely travel on commercial aircraft 2 weeks after resolution of pneumothorax. Ideally, a chest xray should be obtained shortly before travel to confirm that it is gone. Helicopter travel is okay at any time, since they typically fly at 1,500 feet or less.

Divers should see a physician trained in dive medicine to evaluate their injury and imaging prior to making another dive.

Tomorrow: new info on flying after pneumothorax

References:

  • Divers Alert Network – Pneumothorax – click to download
  • Practice Guideline, Orlando Regional Medical Center. Air travel following traumatic pneumothorax. October 2009.
  • Medical Guidelines for Airline Travel, 2nd edition. Aerospace Medical Association. Aviation, Space, and Environmental Medicine 74(5) Section II Supplement, May 2003.

Last Chance To Complete The ED Thoracotomy Survey!

The number of new survey completions is starting to dwindle, so I will be closing the ED thoracotomy survey this Friday at midnight Central time. I’ll pick apart the results and publish them in the next couple of weeks.

I am trying to determine who could and who actually does perform ED thoracotomy across the various trauma hospitals around the world. For those of you who have already completed it, thanks! For everyone else, please take the 2 minutes to finish it soon!

Click here to take the ED thoracotomy survey.

Thanks,
Michael

Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.