Tag Archives: philosophy

What Would You Do? The Elderly Patient With Subdural Hematoma

All trauma centers are seeing a steady increase in the number of elderly patients, particularly victims of falls. Frequently, these patients strike their head, and some develop various flavors of intracranial hemorrhage. Several are taking drugs that interfere with clotting or platelet function.

Many centers, like my own, have developed practice guidelines to help trauma professionals deal with these issues in a consistent fashion. But are the guidelines suitable for all elderly head-injured patients?

Let’s consider a case.

Scenario 1. An elderly female falls at her senior living facility, striking her head on a side table.  She is brought to your center’s emergency department for evaluation. An exam and head CT are performed, which demonstrate an asymptomatic 6mm subdural hematoma with no midline shift. The patient is not taking any drugs that would interfere with clotting. You have a clinical practice guideline that requires neurologic monitoring for 6 hours, followed by a repeat CT scan. If the neurologic exam remains stable and the repeat CT shows no progression of the lesion, the patient may be discharged.

Seems pretty straightforward, right? Now let’s add some interesting tidbits.

Scenario 2. Same as above, but the patient is brought to your center the next morning, 8 hours after the fall.

Scenario 3. Same as scenario 1, but the patient is very demented.

Scenario 4. Same as scenario 1, but the patient has a well-documented “do not actively resuscitate” order in place.

Scenario 5. Same as scenario 1, but the patient is 95 years old.

Think about these carefully. Would the extra findings in scenarios 2-5 cause you to change your practice and diverge from the practice guideline? In what ways? What else do you need to know to make good decisions?

Over my next few posts, I’ll consider each of these cases. I’ll cite some of the pertinent literature that I think we need to know. Then I’ll finish up with my take on each of the scenarios.

As always, feel free to share your thoughts about them. You can email, leave comments at the end of this post, or shout it out on Twitter. I’ll respond to each and every one.

Time for some more philosophy! After providing trauma care for decades, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.

The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Some examples:

  • An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
  • A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
  • A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.

Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.

How To Tell If Research Is Crap

I recently read a very interesting article on research, and found it to be very pertinent to the state of academic research today. It was published on Manager Mint, a site that considers itself to be “the most valuable business resource.” (?) But the message is very applicable to trauma professionals, medical professionals, and probably anyone else who engages in research pursuits. The link to the full article is listed at the end of this post.

1. Research is not good because it is true, but because it is interesting.

Interesting research doesn’t just restate what is already known. It creates or explores new territory. Don’t just read and believe existing dogma.

Critique it.

Question it. Then devise a way to see if it’s really true.

2. Good research is innovative.

Some of the best ideas come from combining ideas from various disciplines.

Some of the best research ideas are derived from applying concepts from totally unrelated fields to your own.

That’s why I read so many journals, blogs, and newsfeeds from many different fields. And even if you are not doing the research, a broad background can help you sort out and gain perspective as you read the works of others.

3. Good research is useful.

Yes, basic bench level research can potentially be helpful in understanding all the nuances of a particular biochemical or disease process.But a lot of the time, it just demonstrates relatively unimportant chemical or biological reactions. And only a very small number actually contribute to the big picture. For most of us working at a macro level, research that could actually change our practice or policies is really what we need.

4. The best research should be empirically derived.

It shouldn’t rely on complicated statistical models. If it does, it means that the effect being measured is very subtle, and potentially not clinically significant. There is a big difference between statistical and clinical relevance.

Reference: If You Can’t Answer “Yes” To These 5 Questions, Your Research Is Rubbish. Garrett Stone. Click here to view on Manager Mint.

Why Is So Much Published Research So Bad?

Welcome to two days of rants about bad research!

I read lots of trauma-related articles every week. And as I browse through them, I often find studies that leave me wondering how they ever got published. And this is not a new phenomenon. Look at any journal a year ago. Five years ago. Twenty years ago. And even older. The research landscape is littered with their carcasses.

And on a related note, sit down with any serious clinical question in your field you want to answer. Do a deep dive with one of the major search engines and try to get an answer. Or better yet, let the professionals from the Cochrane Library or other organization do it for you. Invariably, you will find hints and pieces of the answer you seek. But never the completely usable solution you desire. 

Why is it so hard? Even with tens of thousands of articles being published every year?

Because there is no overarching plan! Individuals are forced to produce research as a condition of their employment. Or to assure career advancement. Or to get into medical school, or a “good” residency. And in the US, Level I trauma centers are required to publish at least 20 papers every three years to maintain their status. So there is tremendous pressure across all disciplines to publish something.

Unfortunately, that something is usually work that is easily conceived and quickly executed. A registry review, or some other type of retrospective study. They are easy to get approval for, take little time to complete and analyze, and have the potential to get published quickly.

But what this “publish or perish” mentality promotes is a random jumble of answers that we didn’t really need and can’t learn a thing from. There is no planning. There is no consideration of what questions we really need to answer. Just a random bunch of thoughts that are easy to get published but never get cited by anyone else.

Bottom line: How do we fix this? Not easily. Give every work a “quality score.” Instead of focusing on the quantity of publications, the “authorities” (tenure committees and the journal editors themselves) need to focus in on their quality. Extra credit should be given to multicenter trial involvement, prospective studies, and other higher quality projects. These will increase the quality score. The actual number of publications should not matter as much as how much high quality work is in progress. Judge the individual or center on their total quality score, not the absolute number of papers they produce. Sure, the sheer number of studies published will decline, but the quality will increase exponentially!

Tomorrow, the big picture view on how to detect bad research.

Pop Quiz: Do We Really Need To Do All That? The Answer

The scenario involved an elderly woman who fell from standing at her care facility 12 hours earlier. They want to send her to your trauma center for evaluation because she seems a bit different from her baseline. You have well defined practice guidelines for patients with head injuries that dictate what type of monitoring and diagnostics they receive.

What do you need to know to determine what you should do? Thanks for all of you who sent in suggestions.

Here are my thoughts:

  • Which scans should she get? Usually, you would obtain an initial head CT and, due to her age, a cervical CT regardless of her physical exam due to the high miss rate in these patients. But now the fun begins. Your subarachdoid / intraparenchymal hemorrhage (IPH) practice guideline would have you admit for neurologic monitoring for 12 hours, obtain a TBI screen, then discharge without a followup scan if the screen was passed. But in this case, the clock started 12 hours ago and the guideline would be finished with the exception of the TBI screen. So an initial scan and a TBI screen in the ED are all that are needed. The observation period is already over and the patient could potentially be discharged from ED if a SAH or IPH were found.
    Your subdural guideline mandates all of the above plus a repeat scan at 12 hours. But once again, the clock has already started. Do you just get an initial scan, which also serves as the 12 hour scan? Or do you get yet another one?  If the neuro exam is normal, I vote for the former, and your evaluation is complete after the TBI screen. If the neuro exam is not quite normal, then admission for continuing exams and a repeat scan are in order.
  • Does the patient need to be admitted, and for how long? Hopefully, you’ve figure this out in the previous bullet. The clock started running when she fell down, so in cases where the physical exam is normal, only the first CT is needed and ongoing monitoring is not. Thus, she could return to her care facility from the ED after the scan.
  • What other important information do you need to know? Of paramount importance is her DNR status and her/her family’s willingness to have brain surgery if a significant lesion is identified. It is extremely important to know the latter item. If there is never any patient or family intent to proceed to surgery, is there any point to obtaining scans at all? In my opinion, no. The whole reason to obtain the scan and monitor is to potentially “do something.” But if the patient and/or family will not let us “do something,” there is no reason to do any of this. It is crucial that the patient and family understand the typical outcomes from surgery given her age and degree of frailty. This is most important in patients who are impaired with dementia or a high-grade lesion  if found from which there is minimal chance of recovery. In most such cases, even if surgery is “successful,” the patient will never recover enough to return to their prior level of care. This should be weighed heavily by the family and care providers.
  • Should a patient with DNR or “no surgery” orders even be sent to the ED? Theoretically, no. There is no need from the standpoint of their future care. They are not really eligible to have any studies or monitoring done. However, the facility may try to insist for their own liability issues, but this is not really a valid clinical reason.

I hope you enjoyed this little philosophical discussion. Feel free to agree/disagree through your comments or tweets!