Category Archives: Philosophy

Philosophy

Stroke And Fall VS Fall And Bleed

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It’s like the old chicken and egg question. When dealing with head trauma and falls, which came first? Did the patient have a stroke and then fall down? Or did they fall and sustain some type of intracranial hemorrhage? And you may ask, does it make a difference? They are going to get a head scan anyway, right?

In my opinion, it makes a big difference! How often have you seen the following scenario? EMS is called to a house or nursing home for someone who has fallen. They notice some extremity weakness on one side and presume the patient is having a stroke. The emergency department is then notified that a stroke patient is inbound.

On arrival, the patient was rapidly assessed and whisked off to CT scan for a CT and angiogram, possibly with neurology present. My experience is that a majority of these scans is negative for CVA. And many are positive for some type of extra-axial hemorrhage like subdural or epidural blood from the real injury.

Unfortunately, something called anchoring bias is likely to occur in this situation. Everyone from the paramedics onward are moving along under the assumption that the patient has had a stroke. They stop considering the more common diagnosis of TBI and other potential injuries in the spine and torso. Even when the CT angiogram is found to be negative, it’s difficult for people to change gears. It then takes longer to address the subdural or epidural. The involved trauma professionals are less likely to activate the trauma team. And further evaluation of the chest, abdomen, and spine may be delayed or forgotten for a time.

Bottom line: In any case of a fall followed by neurological changes that could indicate stroke, always presume a serious TBI first! If EMS requests a stroke code, it should be changed to a trauma activation prior to patient arrival. This takes advantage of the odds (more in favor of TBI) and activates a team that is well versed in evaluating the entire patient. If no evidence of hemorrhagic stroke is present, the team will then order the brain CTA and involve the stroke team as necessary.

And for good measure, every one of these cases that does start as a stroke evaluation should be addressed by the trauma performance improvement process!

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Philosophy

What Is The Curbside Consult?

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Surgeons, I’m sure you’ve had an experience something like this at some point:

You happen to be wandering through the emergency department and one of your Emergency Medicine colleagues approaches you and says, “Hey, I ‘ve got this patient I’m seeing that I just want to run by you…”

How should you deal with this? They want a quick tidbit of information to help them decide what to do with the patient. Can they send them home, or should they “formally” consult you?

It’s important to look at the pros and cons of this practice. First the pros:

  • It’s direct. You’re right there. No phone calls, no paging.
  • It’s quick. Just a quick description  of the problem, and a prompt answer. Then everyone can get on with their business.

But then there are the cons:

  • Situational accuracy. The consultee has not seen the patient, so the information they have been given was filtered through the consulter. Any number of cognitive biases are possible, so the real story may not be exactly as it seems.
  • Interpretation of the recommendation. Other cognitive biases are also possible as the consulter acts on and implements the recommendations of the consulter. Have they really been followed?
  • Lack of documentation. This is the biggest problem with a curbside consult. The consultee may act without documenting the source of the recommendation. Or, they may document that they spoke with Dr. Consultee. In either case, one or the other may be hung out to dry, so to speak.

Consider what happens if there is a complication in the care of that patient. There is no way to really determine what was said during that conversation a week or two years later. It boils down to recollections and may end up as a he said … she said situation. And in the worst case scenario, if such a case were to enter the medicolegal arena, there is no official record that any recommendation was made or followed. It’s a very easy case for the plaintiff’s attorney to prevail.

Those of you who have been following me for some time may be familiar with my Laws of Trauma. Originally, there were ten.

But the curbside consult leads to my new Eleventh Law of Trauma:

“Work not documented is work not done“

Bottom line: There is no such thing as a curbside consult! The consultee should say, “I’d better take a look at this patient, why don’t you officially consult me?”

In doing this, the consulter gets to use their own clinical and cognitive skills, and thus render a real opinion based on first hand experience. The consultee gets the most accurate recommendations possible, and they are noted in the record so there is no room for misinterpretation. And finally, there is good documentation from both that will stand up in a court of law if needed.

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Philosophy

Do I Have To Call My Trauma Team For Incoming Transfers?

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I had a great question sent in by a reader last week:

Some trauma centers receive a number of transfers  from referring hospitals. Much of the time, a portion of the workup has already been done by that hospital. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. The reason you should be activating your team is that you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

  • Physiologic. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
  • Anatomic. Most simple anatomic criteria (e.g. long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
  • Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
  • Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team. 

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Philosophy

What Is The Curbside Consult? And The ELEVENTH Law of Trauma!

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Surgeons, I’m sure you’ve had an experience something like this at some point:

You happen to be wandering through the emergency department and one of your Emergency Medicine colleagues approaches you and says, “Hey, I ‘ve got this patient I’m seeing that I just want to run by you…”

How should you deal with this? They want a quick tidbit of information to help them decide what to do with the patient. Can they send them home, or should they “formally” consult you?

It’s important to look at the pros and cons of this practice. First the pros:

  • It’s direct. You’re right there. No phone calls, no paging.
  • It’s quick. Just a quick description  of the problem, and a prompt answer. Then everyone can get on with their business.

But then there are the cons:

  • Situational accuracy. The consultee has not seen the patient, so the information they have been given was filtered through the consulter. Any number of cognitive biases are possible, so the real story may not be exactly as it seems.
  • Interpretation of the recommendation. Other cognitive biases are also possible as the consulter acts on and implements the recommendations of the consulter. Have they really been followed?
  • Lack of documentation. This is the biggest problem with a curbside consult. The consultee may act without documenting the source of the recommendation. Or, they may document that they spoke with Dr. Consultee. In either case, one or the other may be hung out to dry, so to speak.

Consider what happens if there is a complication in the care of that patient. There is no way to really determine what was said during that conversation a week or two years later. It boils down to recollections and may end up as a he said … she said situation. And in the worst case scenario, if such a case were to enter the medicolegal arena, there is no official record that any recommendation was made or followed. It’s a very easy case for the plaintiff’s attorney to prevail.

So this leads to my new Eleventh Law of Trauma:

“Work not documented is work not done“

Bottom line: There is no such thing as a curbside consult! The consultee should say, “I’d better take a look at this patient, why don’t you officially consult me?”

In doing this, the consulter gets to use their own clinical and cognitive skills, and thus render a real opinion based on first hand experience. The consultee gets the most accurate recommendations possible, and they are noted in the record so there is no room for misinterpretation. And finally, there is good documentation from both that will stand up in a court of law if needed.

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Philosophy

VIP Syndrome In Healthcare (Very Important Person)

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Current events are making this classic post even more poignant!

The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.

Who is a VIP? It may be a celebrity. A family member. Or even a colleague. Or the President of the United States. VIPs (or their healthcare providers) may have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.

Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.

Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.

How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to allproviders who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.

Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.

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