Once again, the trauma world is a little smaller. Yesterday, another great trauma professional passed away, Dr. Norman McSwain. I have known the man for decades, and literally grew up reading about his advancements and accomplishments. It’s interesting that one never truly appreciates the magnitude of those achievements until the person is gone.
Norm was a skilled surgeon and teacher, but his achievements were felt far outside his home in Louisiana. He was an early member of the ACS Committee on Trauma, and was very involved in the development of the Advanced Trauma Life Support and Prehospital Trauma Life Support courses. He is credited with developing the original EMS programs in both Kansas, where he took his first faculty position out or residency, and in New Orleans, his home for the remainder of his life. He spent his career at the Charity Hospital there, weathering multiple political storms over the years, as well as the big one, Hurricane Katrina. He was instrumental in achieving Level I Trauma Center status for its replacement, Interim LSU Hospital.
Norm’s accomplishments are, as many of his contemporaries who have left us, too numerous to count. I certainly won’t try to recount them here. But it was his charm, his love for his charges, and his willingness to teach every trauma professional that will always be remembered.
I’ll leave you with his 18 rules of patient care. They are timeless, and will serve you well regardless of your degree and level of medical training.
Most trauma professionals worry about over-prescribing pain medication. But under-prescribing can create problems as well. Uncontrolled pain is a huge patient dissatisfier, and can lead to unwelcome complications as well (think pneumonia after rib fractures). Always do the math and make sure you are sending the right drug in the right amount home with your patient. If the patient’s needs are outside the usual range, work with their primary provider or a pain clinic to help optimize their care.
#8. Improper care during an emergency
This situation can occur in the emergency department when the emergency physician calls a specialist to assist with management. If the specialist insists on the emergency physician providing care because they do not want to come to the hospital, the specialist opens themselves up to major problems if any actual or perceived problem occurs afterwards. The emergency physician should be sure to convey their concerns very clearly, tell the specialist that the conversation will be documented carefully, and then do so. Specialists, make sure you understand the emergency physician’s concerns and clearly explain why you think you don’t need to see the patient in person. And if there is any doubt, always go see the patient.
#9. Failure to get informed consent
In emergency situations, this is generally not an issue. Attempts should be made to communicate with the patient or their surrogate to explain what needs to happen. However, life or limb saving procedures must not be delayed if informed consent cannot be obtained. Be sure to fill out a consent as soon as practical, and document any attempts that were made to obtain it. In urgent or elective situations, always discuss the procedure completely, and provide realistic information on expected outcomes and possible complications. Make sure all is documented well on the consent or in the EHR. And realize that if you utilize your surrogates to get the consent (midlevel providers, residents), you are increasing the likelihood that some of the information has not been conveyed as you would like.
#10. Letting noncompliant patients take charge
Some patients are noncompliant by nature, some are noncompliant because they are not competent (intoxicated, head injured). You must use your judgment to discern the difference between the two. Always try to act in the best interest of your patient. Document your decisions thoroughly, and don’t hesitate to involve your legal / psych / social work teams.
#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.
Tune in for the final installment in my next post.
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.
Ever wonder what is going on when you drag your mouse across a CT image, or when you change the “window” settings of an image from lung to abdomen? It all has to do with the way CT generated xray information is displayed, and how your eyes and brain perceive it.
Let’s get down to basics. The first thing needed is to understand the concept of radiodensity. The CT scanner uses a set of software algorithms to determine the amount of x-radiation absorbed by every element in a plane of tissue. Each of these elements is represented by a pixel on the video display, and the density (amount of x-radiation absorbed) is measured in Hounsfield units. This scale was developed by Sir Godfrey Hounsfield, who set the radiodensity of water at 0, and air at -1000. The scale extends in the positive direction to about +4000, which represents very dense metals. See the table for the density of common substances on CT.
When you view a CT scan on a video display, two important numbers are displayed on screen. The first is the window width (W), which describes the range of Hounsfield units displayed. The maximum window width possible is usually about 2000, but our eyes are not capable of seeing this many shades. Actually, we can really only distinguish about 16 shades of gray. So the window width is divided by 16, and each group of Hounsfield values is converted to one of 16 shades of gray. The lowest Hounsfield numbers in the window range are shown as black, and the highest are white.
The second important number is the window level (L). This is the Hounsfield number in the center of the window width. So let’s look at some typical examples of W/L settings.
The abdomen contains mostly soft tissue, which is just a little denser than water. So most of the abdominal contents have Hounsfield values from 0 to 100 or so. A typical abdominal scan W/L setting is 350/50. This means that a total range of 350 different densities are displayed, centered on a density of 50 Hounsfield units ( range is -125 to 225 HU). Each difference of 22 HU will show up as a different shade of gray. So this narrow window allows us to distinguish relatively subtle differences in density.
The chest cavities are primarily air-filled, and the lungs are very low density. So it makes sense that a typical lung W/L setting is 1500/-500. The window ranges from -1250 to +250 HU, and a wider range of 94 HU represents one shade of gray. This is typical of body regions with a wider range of densities.
Finally, bone windows are usually 2000/250. This window is centered above the usual tissue densities, and is very wide so that it shows a wide range of densities in only 16 shades of gray. Thus, the contrast appears very low.
On most displays, the window width increases as you drag the mouse to the right. This increases the range of densities in a shade of gray, thus decreasing the overall amount of contrast in the image. Dragging the mouse down decreases the window level, moving it toward the air end of the spectrum. This allows you to center your window on the type of tissue you are interested in viewing and adjust your ability to distinguish objects with a lot or only a little contrast (see table above).
I apologize to my radiology colleagues in advance for this simplistic explanation. Trauma professionals have minimal exposure (pun intended) to the physics and details of radiographic imaging. We are much more interested in effectively using this technology to save our patients’ lives.
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