All posts by TheTraumaPro

Is Applying Or Removing That Cervical Collar Dangerous?

Cervical collars are applied to blunt trauma patients all the time. Maybe a bit too often. And most of the time, the neck is fine. It’s just those few patients that have fracture or ligamentous injury that really, truly need it.

I’ve previously written about how good some of the various types of immobilization are at limiting movement (click here). But what happens when you are actually putting them on or taking them off? Could there be dangerous amounts of movement then?

Several orthopaedics departments studied this issue using an electromagnetic motion detector on “fresh, lightly embalmed cadavers” (!) to determine how much movement occurred when applying and removing 1- and 2-piece collars. Specifically, they used an Aspen 2-piece collar, and an Ambu 1-piece. They were able to measure flexion/extension, rotation and lateral bending.

Here are the factoids:

  • There were no significant differences in rotation (2 degrees) and lateral bending (3 degrees) when applying either collar type or removing them (both about 1 degree)
  • There was a significant difference (of 0.8 degrees) in flexion/extension between the two types (2-piece flexed more). Really? 0.8 degrees is significant? Not clinically!
  • Movement was similarly small and not significantly different in either collar when removing them

Bottom line: Movement in any plane is less than 3-4 degrees with either a 1-piece or 2-piece collar. This is probably not clinically significant at all. Just look at my related post below, which showed that once your patient is in the rigid collar, they can still flex (8 degrees), rotate (2 degrees) and move laterally (18 degrees) quite a bit! So be careful when using any collar, but don’t worry about doing damage if you use it correctly.

Related post:

Reference: Motion generated in the unstable cervical spine during the application and removal of cervical immobilization collars. J Trauma 72(6):1609-1613, 2012.

Sinus Precautions: Another Trauma Urban Legend?

The trauma service typically helps our facial surgery colleagues manage patients from time to time. Every now and again, I see their request/instructions for “sinus precautions” when patients have certain fracture patterns or undergo surgery involving sinuses.  Where did these “precautions” come from? Do they really make sense?

The paranasal sinuses shown above are the most commonly injured after facial trauma. They are lined with mucosa, and like the rest of our body, colonized with bacteria. They are interconnected with each other and the nasal cavity via tiny ostia that allow for normal drainage into the nose. Facial surgeons worry that these bacteria may seep out of fractured areas into clean tissue and cause deep infections. This may occur spontaneously, and could be accelerated if the pressure in the sinuses is increased in any way.

If you do a simple internet search on “sinus precautions”, it seems like every facial surgery group in the country has a set in their patient information sheet. And they all look suspiciously similar. As if they’ve been copied from each other and over, and from the same very, very old document.

As noted above, the main issue to be avoided is increasing pressure across the sinuses. Here’s the usual list of precautions, and my comments on their utility.

  • Avoid blowing your nose. This one actually makes sense. Closing the nose and mouth, pressurizing the pharynx and releasing through the nose will certainly increase sinus pressures. And there are actually reported cases of new onset cellulitis after this maneuver. True
  • Avoid sneezing. Good luck on this one. Who actually does this on purpose anyway? Sneezing will certainly increase sinus pressures, but this can be minimized by avoiding trying to stifle the sneeze. True
  • Do not drink through a straw. What? This causes a low pressure zone in the oropharynx so that fluids can be sipped, but the nasopharynx is isolated. If it weren’t you’d have beverages pouring out of your nose. False
  • Do not smoke. Well, this is certainly a good idea for many reasons, but has little impact on nasopharyngeal pressures. If anything, it decreases them slightly on inhalation, and works the same on exhalation as breathing out without the smoke. False
  • Do not blow musical instruments, balloons, … Yes, this can increase pressures. True
  • Do not push or lift heavy objects.  Hmm. The natural tendency is to perform a Valsalva maneuver (holding breath against a closed glottis) when doing this. In theory, this shouldn’t impact the sinuses because they are not attached to the trachea in any way. And even though it is possible to let some air escape the glottis and keep your mouth closed, it immediately exits the nose. Exhaling through the nose rapidly could increase pressures slightly. Most people don’t do this. Mostly false
  • Do not bend over, keep your head above your heart, sleep with your head slightly elevated. Come on, now. Sinuses are rigid, air-filled cavities. They don’t compress. False
  • Do not fly in a plane.  Definitely an issue. Everybody experiences popping ears and sinuses when flying. And it’s the descent that is of most concern. The increasing air pressure during this phase of flight can push fluid and air out of the sinuses. True
  • Do not spit. Okay, this goes without saying. It’s rude, but doesn’t do a thing to your sinuses. False

Bottom line: I was unable to find any seminal paper or book chapter as the source for “sinus precautions”. Most of the items on the list are bogus. But a few do actually increase sinus pressures and could result in fluid, air, and bacteria moving out of sinuses and into areas where they don’t belong. Pare down the list before you hand it to your patients.

The September Trauma MedEd Newsletter Is Coming Soon: Trauma in the Hybrid Room

A growing number of hospitals have a “hybrid OR.” My next newsletter will answer all your questions about what it is, and what you can do in it. It can be a handy dandy tool for trauma cases, but there are a number of things you need to think about before you use it for the first time.

In this issue I’ll cover:

  • What exactly is a hybrid OR?
  • What types of trauma cases can it be used for?
  • What are the limitations?
  • What do I need to think about before I use it for trauma?
  • And more!

As always, this issue will go to all of my subscribers first. If you are not yet one of them, click this link to sign up and/or download back issues.

Unfortunately, non-subscribers will have to wait until I release the issue on this blog, about 10 days later. So sign up now!

Nurses: Stop The Insanity! What To Do When The Doc Won’t Listen

“Insanity: doing the same thing over and over again and expecting different results.”

– Albert Einstein

This post applies specifically to nurses. I know it’s happened to you. Your patient is having a problem. You do a little troubleshooting, but you feel that a doctor needs to know and possibly take some action. So you page them and duly note it in the medical record. No response. You do it again, and document it. No response. And a third time, with the same result.

And now what? Call someone else? Give up and hope the patient improves?

What if the doctor on call is a known asshole? Are you even reluctant to call in the first place? Do you delay as long as you possibly can?

Believe it or not, I’ve seen many chart review cases over the years where this situation does arise. And every once in a while, the patient actually dies. Sometimes this is directly related to the lack of intervention, but sometimes it just sets the ball rolling that eventually leads to patient demise days or weeks later.

What’s the answer? We all want to provide the best care possible for our patients. But sometimes social factors (or pager malfunctions) just get in the way. Here’s how to deal with it.

Every hospital / nursing unit needs to have a procedure for escalating patient care calls to more advanced providers. When one of your patients develops a problem, you usually have a pretty good idea of what the possible solutions are. So call/page the proper person (PA/NP/MD) who can provide that solution. If they don’t give you the “right answer”, then question it. They are not all-knowing.

If they give you a good explanation, go with it, but keep your eye on your patient’s progress. If they can’t explain why they are giving you the wrong answer, suggest they check with someone more senior. And if they don’t want to, let them know that you will have to. Consider no answer the same as a wrong answer.

Don’t stop going up the chain of command until you get that right answer, or an explanation that satisfies you. The hard part here is going up the chain. You may not be comfortable with this. But you do have resources that can help you that have more authority (nurse manager, supervisor, etc). If they, too, are uncomfortable, then your hospital has much bigger problems (unhealthy workplace). 

Example: trauma unit nurses at my hospital will call the first year resident first, then escalate to the junior and/or chief residents. If they don’t do the right thing, the in-house trauma attending gets the call. If they don’t handle it, then the trauma medical director (me) gets called. And, of course, I always do the right thing (chuckle). And our nurses know that the surgeons support them completely, since this facilitates the best patient care. The residents and PAs are educated about this chain of command when they first start on the trauma service, and it makes them more likely to choose the “right answer” since they know the buck may not stop with them.

More on Malpractice: Can Surgical Residents Be Sued?

Respondeat superior. Let the master answer. This is a common law term that allows employers to be held responsible for the misdeeds of their employees or agents.

And more than half a century ago, the “captain of the ship” doctrine arose in surgery. This held the supervising surgeon responsible for everything that happened in the operating room.

And because of these two premises, there has been widespread presumption that surgical trainees are immune to being named in a malpractice action. Unfortunately, this is not true! There is no law that prevents residents from being included in a lawsuit.

So how common is resident involvement in malpractice suits? What are the damages? What are the consequences?  Researchers at the Mayo Clinic reviewed 10 years of data from the Westlaw online legal research database. They included all cases that involved surgical interns, residents, or fellows.

Here are the factoids:

  • A total of 87 malpractice cases involving surgical trainees were identified over 10 years (!)
  • 47% involved general surgical cases, 18% orthopedics, and 11% OB. The remainder were less than 5% each.
  • 70% of cases involved elective surgical procedures. The most common one was cholecystectomy (6 cases).
  • Half involved nonoperative decision making, and 39% involved intraoperative errors and injuries. The remainder had both components.
  • Failure of the trainee to evaluate a patient in person was cited in 12% of cases.
  • Lack of attending supervision was involved in 55%.
  • Informed consent issues were cited in 21%, documentation errors in 15%, and communications problems in 10%
  • There were twice as many cases involving junior residents compared to seniors and fellows
  • Median payout to the patient (and his attorney) was about $900K

Bottom line: At first, I though this was going to be an interesting paper. But it went downhill as soon as I started to read the analysis. Yes, it scanned 10 years worth of detailed malpractice data. BUT IT DIDN’T GIVE US A DENOMINATOR! There must have been tens of thousands of surgical malpractice cases during that time period across the US. And they found only 87 involving surgical trainees!

The authors conclude that this work “highlights the importance of perioperative management, particularly among junior residents, and appropriate supervision by attending physicians as targets for education on litigation prevention.”

This is ridiculous. The mere fact that the authors do not mention the total number of surgical malpractice cases in the database over the study period (denominator) implies that they were trying to emphasize the numbers they did publish. They didn’t want to show you how low the resident numbers were by comparison. On average, 9 were involved in a lawsuit every year. 

How many surgical residents and fellows are there? This is a bit hard to pin down. There are roughly 1200 categorical surgical residency spots every year. And then there are some prelim spots. Let’s add a few thousand more (wild ass guess), so that puts us at 5,000. Include orthopedics and other surgical specialty residencies? Add a few thousand more. And then fellows. Who knows? Add another  thousand? (If anybody has more accurate answers, please leave a comment!)

So 9 out of 10,000+ surgical trainees get sued every year. Do we really need to set up some kind of formal education on malpractice avoidance??? Not for those numbers. Just read, see your patients, especially when they are having problems, document everything you do, and practice good handoff communications. Then worry about more important things!

Reference: Medical malpractice lawsuits involving surgical residents  JAMA  Surg, published online Aug 30, 2017  

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