Category Archives: General

Trauma Mythbusters: NSAIDs And Fracture Healing

Trauma hurts like hell. Over the years, we’ve developed quite a few ways of combating this pain. A number of drug classes have been developed to reduce it. One of the more common non-narcotic drug classes are the NSAIDs. As I’ve mentioned before, every drug has dozens of effects. Drug companies market a particular medication based on one of the predominant effects. All the others are considered side effects.

NSAIDs are not unique; they have lots of side effects as well. In 2003, several papers brought to light possible interactions between these drugs and fracture healing. Specifically, there were questions about these drugs interfering with the healing process and of increasing the number of delayed unions or nonunions. But once again, how convincing were these papers, really?

It would seem to make sense that NSAIDs could interfere with bone healing. This  process relies heavily on the regulation of osteoblast and osteoclast function, which itself is regulated by prostaglandins. Since prostaglandins are synthesized by the COX enzymes, COX inhibitors like the NSAIDs should have the potential to impair this process. Indeed, animal studies in rats and rabbits seem to bear this out.

But as we have seen before, good animal studies don’t always translate well to human experience. Although a study from 2005 suggested that NSAID administration in older patients within 90 days of injury had a higher incidence of fracture nonunion, the study design was not a very good one. It is equally likely that patients who required these drugs in this age group may have been at higher risk for nonunion in the first place.

In fact, there are no large, prospective randomized studies that have explored the effect of short-term or long-term NSAID administration on fracture repair. But there have been several smaller studies that showed absolutely no effect on nonunion with short-term administration of this drug class. Yet the dogma that leads us to avoid giving these drugs persists.

Bottom line: Once again, the animal data is clear but the human data is not. Although there are theoretical concerns about their use, there is not enough solid risk:benefit information to abandon short-term NSAID use in patients who really need them. NSAIDs can and should be prescribed in patients with short-term needs and simple fractures.

References:

  1. Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing. J AM Acad Orthop Surg 12:139-43, 2004.
  2. Effect of COX-2 on fracture-healing in the rat femur. J Bone Joint Surg Am 86:116-123, 2004.
  3. Effects of perioperative anti-inflammatory and immunomodulating therapy on surgical wound healing. Pharmacotherapy 25:1566-1591, 2005.
  4. Pharmacological agents and impairment of fracture healing: what is the evidence? Injury 39:384-394, 2008.
  5. High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth 52:506-512, 2005.
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Trauma Mythbusters: Removing Bullets With Metal Instruments

I’ve heard this time and time again over the years. Don’t remove a bullet using metal forceps or a hemostat. Don’t drop it into a metal pan. Have you heard these, too? Is it true?

The idea is that rifling marks on the bullet that would help match it to a particular weapon may be damaged through mishandling, interfering with any criminal investigation.

So I decided to go to a reputable source. I asked a local police firearms and munitions expert the question. The result:

Myth busted! The amount of damage to the bullet due to handling with metal instruments is negligible and will not interfere with an investigation. Many of the bullets used in crimes are jacketed with copper or other metals, which are resistant to damage anyway. The surgeon would have to make an intentional effort to damage the bullet enough to interfere with a ballistics investigation. And I don’t recommend that anyway!

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When To Call: Urology

Here’s the first in a series of “When To Call” pieces. We sometimes overuse our consultants and call then at inappropriate times. So what if we diagnose an injury in their area of expertise at 2 am? Does it need attention or an operation before morning? If not, why call at that ungodly hour?

Let’s use our consultants wisely! I’ve listed most of the common urologic diagnoses that trauma professionals will encounter. There is also an indication of what you need to do, and exactly when to call your consultant.

Here’s a reference sheet formatted at a 3×5 index card that you can keep in your pocket. I’ve included a printable pdf file, as well as the original Microsoft Publisher file in case you want to make a few modifications to suit your own hospital.

Enjoy!

When to call Urology reference card (pdf)

When to call Urology MS Publisher file (pub)

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December Trauma MedEd Newsletter Released!

The December newsletter is now available! Click the link below to download. This month’s issues some of the best abstracts (in my opinion) that will be presented at the EAST meeting next month. There are a lot of them, so I’m continuing this theme into the January issue..

In this issue you’ll find articles on:

  • Brain hypoxia after TBI during aeromedical evacuation
  • N-acetylcysteine (mucomyst) and pulmonary infection
  • (F)utility of tramsfusion in flight?
  • (F)utility of CPR in hemorrhagic shock
  • Scene time and mortality
  • Lower mortality in patients taking new oral anticoagulants compared to warfarin (how not to write your abstract)

Subscribers received the newsletter last Sunday night. If you want to subscribe to get early delivery in the future (and download back issues), click here.

Click here to download newsletter.

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Trauma Care And HIPAA Demystified

There is a lot of confusion and misinformation out there regarding HIPAA (Health Insurance Portability and Accountability Act). This law was enacted in 1996 with the intent of protecting the health insurance benefits of workers who lose or change their jobs, providing standards for electronic health care transactions, and protecting a patient’s sensitive health information. This last part has caused much grief among trauma professionals.

It is commonplace for a trauma patient to require the services of many providers, from the initial prehospital crew, doctors and nurses at the initial hospital, yet another ambulance or aeromedical crew, professionals at a receiving trauma center, rehab or transitional care providers, and the patient’s primary physician to name a few. Unfortunately, because there can be significant financial penalties for violating the HIPAA privacy guidelines, providers are more likely to err (incorrectly) on the side of denying information to others outside their own institution.

All of the people mentioned above are considered “covered entities” and must abide by the HIPAA Privacy Rule. This rule allows us to release protected information for treatment, payment and “health care operations” within certain limits. The first and last items are the key provisions for most trauma professionals.

Treatment includes provision, coordination and management of care, as well as consultations and referrals (such as transferring to a trauma center). Think of this as the forward flow of information about your patient that accompanies them during their travels.

Health care operations include administrative, financial, legal and quality improvement activities. These quality improvement activities depend on the reverse flow of information to professionals who have already taken care of the patient. They need this feedback to ensure they continue to provide the best care possible to everyone they touch.

Bottom line: Trauma professionals do not have to deny patient information to others if they follow the rules. Obviously, full information must be provided to EMS personnel and receiving physicians when a patient is transferred to a trauma center. But sending information the other way is also okay when used for performance improvement purposes. This includes providing feedback to prehospital providers, physicians, and nurses who were involved in the patient’s care at every point before the transfer. The key is that the information must be limited and relevant to that specific encounter.

Feedback letters and forms, phone conversations and other types of communications for PI are fine! But stay away from email, which is not secure and is usually a violation of your institutional privacy policies.

Always consult your hospital compliance personnel if you have specific questions about HIPAA compliance.

Reference: HIPAA Privacy Rule

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