Category Archives: Philosophy

Philosophy

Geriatric Week 1: How We Take Care Of Our Elders

Leave a comment

Time for some philosophy again. A paper in Neurology released ahead of print confirms something I’m seeing more and more often. Specifically, hospitals can be bad for you, particularly if you are elderly.

The trauma population that we all see is aging with the overall population. Being older predisposes one to injuries that are more likely to require hospitalization. And unfortunately, being in the hospital can have adverse effects. I’m not just talking about the usual culprits such as medical errors or exposure to resistant bacteria.

The Chicago Health and Aging Project has been tracking a group of elders as they age, and has been making a number of interesting observations. Most recently, they have released information on a correlation between cognitive decline and hospitalization. They tracked nearly 1900 people, of whom 1335 ending up in the hospital for one reason or another (not just trauma). They found that there is a baseline rate of global cognitive decline with age (surprise!). Unfortunately, this rate of decline accelerated 2.4 times in the hospitalized group. Episodic memory scores declined 3.3 times faster, and executive function declined 1.7 times faster. And declines tended to be more pronounced in patients who had more severe illness, longer hospital stay, or advanced age.

There are some issues with the study. It is large, but it is a correlation study nonetheless. Are the effects due to something that happens in the hospital, or are they caused by something not evaluated by the study? It’s also not clear to me whether the declines noted are clinically significant in the daily lives of the people studied, or are just a number on some scale.

Bottom line: Some of the “benign” things that we do to patients in the hospital can have a big impact on their functional outcome. Always remember that they are more fragile than the young trauma patients we take care of. That extra fluid bolus, or dose of morphine, exposure to IV contrast, or noisy neighbor that keeps them from sleeping can make a real difference in how they do. Always consider that everything you do to them might kill them. Then seriously reconsider whether you really, really need to order it at all.

Reference: Cognitive decline after hospitalization in a community population of older persons. Neurology, 78(13):950-956, 2012.

Print Friendly, PDF & Email
Philosophy

Another Failure Of Shotgun Style Diagnostic Testing: The Trauma Incidentaloma

Leave a comment

When our patients present with a problem, there is a time honored and well-defined sequence to help us come to a final diagnosis.

  • Take a detailed history
  • Examine the patient
  • Order pertinent diagnostic tests, if indicated
  • Then think about it a while

The first two items are a chip shot, and the trauma professional can gain a lot of information by spending a relatively short period of time doing these. And many times the diagnosis can be made without any further action.

However, diagnostic testing of all kinds has become so prevalent and easy to obtain that we rely on it a bit too much. And sometimes, we order it up in lieu of a thorough history and exam. If the clinician skimps on those steps, it’s much more difficult to narrow the list of differential diagnoses to a manageable number.

So what happens then? They use diagnostic tests as a crutch. Instead of being able to select a few focused tests to answer the questions, they essentially put an order sheet on the wall, fire off a shotgun, and order everything that’s been hit by the pellets.

Lots of tests, so they will definitely find the answer, right? Nope! There are two major problems here. First, the so-called signal to noise ratio is very low. There are so many results, that it is easy to overlook a pertinent positive among all the negatives.

But more significantly, there is always the possibility that there will be more than one positive. One of them might actually be the answer you were seeking. But what about the others? There are the trauma incidentalomas. Some may be truly positive, but there is always the possibility of a false positive. These are the most treacherous, because many trauma professionals then feel obligated to “do something about it.”

As we have found from multiple screening tests like PSA, PAP smear, and mammography, a significant number of patients may be harmed trying to further investigate what turns out to be nothing at all (artifact), or something completely benign. This includes not only harm from complications or unnecessary procedures, but months of anxiety the patient may suffer while the clinicians figure out what that thing inside them really is.

There are only a few studies on trauma incidentalomas available. One reviewed a series of almost 600 head CT scans in patients with TBI and found unexpected findings on 85%. About 90% were obviously benign. Unfortunately, it was not possible to follow these patients to find out how many of the remaining lesions turned out to be benign as well. But I would wager that most did.

Bottom line: I shouldn’t even have to say this, but do a good history and physical exam! If you need diagnostic studies, order only the one(s) that have the potential to make your final diagnosis. Don’t shotgun it. One very helpful tool is a well-designed practice guideline for commonly encountered clinical scenarios. This will limit the number of “other” findings you have to deal with. And finally, did I say to do a good history and physical exam?

Related posts:

Reference: Incidental cranial CT findings in head injury patients in a Nigerian tertiary hospital. J Emerg Trauma Shock 8(2):77-82, 2015.

Print Friendly, PDF & Email
Philosophy

Why Is NPO The Default Diet For Trauma Patients?

Leave a comment

I’ve watched it happen for years. A trauma patient is admitted with a small subarachnoid hemorrhage in the evening. The residents put in all the “usual” orders and tuck them away for the night. I am the rounder the next day, and when I saunter into the patient’s room, this is what I find:

They were made NPO. And this isn’t just an issue for patients with a small head bleed. A grade II spleen. An orbital fracture. Cervical spine injury. The list goes on.

What do these injuries have to do with your GI tract?

Here are some pointers on writing the correct diet orders on your trauma patients:

  • Is there a plan to take them to the operating room within the next 8 hours or so? If not, let them eat. If you are not sure, contact the responsible service and ask. Once you have confirmed their OR status, write the appropriate order.
  • Have they just come out of the operating room from a laparotomy? Then yes, they will have an ileus and should be NPO.
  • Are they being admitted to the ICU? If their condition is tenuous enough that they need ICU level monitoring, then they actually do belong to that small group of patients that should be kept NPO.

But here’s the biggest offender. Most trauma professionals don’t think this one through, and reflexively write for the starvation diet.

  • Do they have a condition that will likely require an emergent operation in the very near future? This one is a judgment call. But how often have you seen a patient with subarachnoid hemorrhage have an emergent craniotomy? How often do low grade solid organ injuries fail if they’ve always had stable vital signs? Or even high grade injuries? The answer is, not often at all! So let them eat!

Bottom line: Unless your patient is known to be heading to the OR soon, or just had a laparotomy, the default trauma diet should be a regular diet! 

Print Friendly, PDF & Email
Philosophy, protocols

The Post-Crunch Debriefing

Leave a comment

Trauma centers generally design their trauma teams around the type and volume of injured patients they receive. There must be sufficient depth of coverage to handle multiple “hits” at once. But even the best planning can be overwhelmed by the occasional confluence of the planets where multiple, multiple patients arrive during a relatively short period of time (the “crunch”).

As the reserve of available trauma professionals to see new, incoming patients dwindles, it sometimes even becomes necessary to close the center to new patients. Once those who have already arrived have been processed, the trauma center can open again.

This scenario, while hopefully rare, unfortunately introduces a huge opportunity for errors and omissions in care. There is much more clinical activity, lots of patient information to be gathered and processed, and many decisions to be made. How can you reduce the opportunity for these potential problems?

Consider a “post-crunch” debriefing! Once things have quieted down, assemble all team members in one room. Systematically review each patient involved in the “crunch”, going through physical exam, imaging, lab results, and the final plan. It’s helpful to have access to the electronic medical record during this process so everything that is known can be reviewed. Make sure that all clinical questions are answered, and that solid plans are in place and specific people are assigned to implement them.

Once you’ve reviewed all of the incoming, don’t forget your patients already in the hospital. Significant issues may have occurred while you were busy, so quickly review their status as well. Chat with their nurses for updates. Make sure they are doing okay.

Then prepare yourself for the next “crunch”!

Related post:

Print Friendly, PDF & Email
Philosophy

Why People Don’t Change Their Minds Despite The Data

Leave a comment

Has this happened to you?

Your (emergency physician / neurosurgeon / orthopaedic surgeon) colleague wants to (get rib detail xrays / administer steroids / wait a few days before doing a femur ORIF). You question it based on your interpretation of the literature. You even provide a stack of papers to them to prove your point. Do they buy it? Even in the presence of randomized, double-blinded, placebo-controlled studies with thousands of patients (good luck finding those)?

The answer is generally NO! Why not? It’s science. It’s objective data. WTF?

Sociologists and psychologists have shown that there is a concept that they call the Backfire Effect. Essentially, once you come to believe something, you do your best to protect it from harm. You become more skeptical of facts that refute your beliefs, and less skeptical of the items that support them. Having one’s beliefs challenged, even with objective and authoritative data, causes us to hold them even more deeply. There are plenty of examples of this in everyday life. The absence of weapons of mass destruction in Iraq. The number of shooters in the JFK assassination. President Obama’s citizenship.

Bottom line: It’s human nature to try to pick apart a scientific article that challenges your biases, looking for every possible fault. It’s the Backfire Effect. Be aware of this built in flaw (protective mechanism?) in our psyche. And always ask yourself, “what if?” Look at the issue through the eyes of someone not familiar with the concepts. If someone challenges your beliefs, welcome it! Be skeptical of both them AND yourself. You might just learn something new!

Print Friendly, PDF & Email