And here’s the last in my short “When To Call” series. This one’s a little different, and quite a bit longer. That’s due to the complexity and sheer number of potential orthopedic problems.
When consulting a specialty service, always keep the patient paramount in your decision making. Then think about how soon and under what context they really need to see the patient. Can it wait until morning? Do they even really need to be seen in the ED, or can this be an outpatient visit?
Tomorrow: Expectations on how your consultants should go about their business when seeing your patients.
I’m kicking of a week-long series for trauma program leaders that explains the details of a trauma center requirement that creates confusion for many. With the adoption of the 2014 Resources for Optimal Care of the Injured Patient (i.e. The Orange Book), a number of new requirements were introduced to obtain and maintain status as an American College of Surgeons verified trauma center. One (or actually two) of the requirements for Level I and II centers are known collectively as the 30-minute rules.
The 30-minute rules apply to both orthopedic surgeons and neurosurgeons. They state that care must be continuously available and that a service representative “must be present and respond within 30 minutes based on institutional-specific criteria.” And most who peruse the Orange Book have already realized, any phrase that contains the word must denotes that failure to meet the requirement will result in a deficiency during a site review, whereas the word shall means that it will likely result in a weakness.
For the rest of the week, I’ll work through these requirements. I will describe what they mean and what some typical institutional-specific criteria are. I will explain who is actually required to respond. I’ll work through the logistics of being able to accurately record their response time, and offer best practices for how to capture it. And finally, I’ll look at the consequences of not meeting these criteria.
Tomorrow: Typical criteria for orthopedic surgery and orthopedics.
Level I and II trauma centers that are verified by the American College of Surgeons are required to have a method for ensuring that urgent orthopedic cases have good access to an operating room (OR). Some hospitals (that have room availability) have achieved this by dedicating an OR for this purpose. In a few hospitals, the room is available 24/7, but most provide daily block time that has a reasonable release time (typically about 6am). This allows procedures to reliably get done the next morning.
Previous papers have documented many of the benefits of this practice: decreased length of stay, fewer surgical revisions, decreased cost, and of course, fewer after-hours operations. But by definition, this adds a delay of several hours to the case. If the patient comes in at 7pm, the case may not start for 12 hours or more.
Could this increase the risk of infection or other complications? The orthopedic group at Stormont Vail in Topeka KS (Level I) looked at their retrospective experience over a 6 year period. They specifically examined cases in which a time delay could increase the infection rate: open tib/fib fractures. They recorded the usual demographics, time to procedure, and broke the data down by Gustilo grade of the fracture.
Here are the factoids:
The authors treated 297 patients with a total of 347 open fractures
About half were treated before a dedicated ortho OR was implemented, and half after
Average time to debridement in the dedicated OR was 13 hours, vs 5 hours in the on-call system
Overall, the number debrided within 24 hours was the same in both groups
Primary fracture union was significantly higher in the dedicated room group (73% vs 57%)
Patients treated initially in the dedicated room were significantly less likely to need an unplanned procedure later (for malunion or infection)
There was no difference in infection, non-union, or amputation rates
Bottom line: Let your orthopedic surgeon sleep if you have a dedicated OR so the work can get done first thing the next day! It saves wear and tear on the hospital infrastructure that occurs when cases are done in the middle of the night, as well as the surgeon. Besides saving time and money, final outcomes are better, too!
Reference: Use of the Dedicated Orthopaedic Trauma Room for Open Tibia and Femur Fractures: Does It Make a Difference? J Ortho Trauma 32(8):377-380, 2018.
Anatomy is complex and confusing at times. Pretty much everything you can find in the human body has a name. Sometimes it makes sense. Sometimes it’s named after someone famous. And sometimes, it’s just a head-scratcher.
Let’s take the surgical neck of the humerus. Here’s an image of the proximal humerus:
Notice there are two different “necks” of the humerus. You are probably familiar with the anatomic neck from your anatomy classes. But if you are a resident, an orthopedic surgeon, or someone who deals with fractures regularly, you are more familiar with the surgical neck.
The surgical neck of the humerus is the most common fracture site on the proximal humerus. But here’s the kicker. It’s a misnomer!
Just because you see a fracture of the surgical neck of the humerus doesn’t meed it needs surgery! Indeed, many of these fractures are now successfully treated with immobilization in a sling. Your friendly neighborhood orthopedic surgeons will assess fracture stability by looking at the mechanism, exact location, involvement of the tubercles, and motion. Then they will decide on their treatment plan.
Bottom line: Don’t get suckered when someone asks you what operation is usually needed for a fracture of the surgical neck of the humerus!