• Who first saw the patient? Usually a triage nurse will evaluate the patient before the patient is officially checked into the emergency department (ED).
• How did the patient arrive at the ED: by car, squad, or helicopter?
• When did the patient go to the ED in relation to the accident? Was the patient seen in the ED the same day or was the visit delayed?
• If the visit did not occur the same day as the accident, what was the reason provided for the patient’s delay in seeking medical care at the emergency department? Does the record say “Patient instructed to go to ED by his attorney?”
• What were the complaints of the patient? Were these the same complaints documented by the rescue squad at the accident scene?
• What were the injuries? If the patient was rear-ended, are low back or cervical spine symptoms documented? (These symptoms may not occur until twenty-four hours or more after the accident.) Were lacerations severe enough to be sutured? What x-rays were taken, and what did they show? If the patient complained of pain in a limb, was the correct limb x-rayed?
• Is there documentation of the use of a seat belt? Is the patient described as having been restrained at the time of the accident? Often this fact is changed in subsequent records. At times the patient who is unrestrained at the time of the accident may claim to have been using a seat belt when giving a history of the accident to a treating physician.
• Did the patient report a loss of consciousness at the accident scene? Is this consistent throughout subsequent records?
• Did the patient have chronic medical conditions? Look for seizure disorder and transient ischemic attacks (potential for raising questions of liability), arthritis (pre-existing condition), deafness (potential for raising questions on liability), hypoglycemia (drop in blood sugar which may result in lowered attention and may contribute to causing an accident), and glaucoma or cataracts (decreased vision may have contributed to the accident, particularly if it occurred after dark).
• What medications was the patient taking on a routine basis at the time of the accident? Look for sedatives and narcotics, which may cause drowsiness. Use of narcotics or other pain relievers raise questions about pre-existing conditions. Use of eye drops raise issues concerning visual acuity. A history of treatment with antidepressants may be significant if the patient claims to have developed depression as a result of the accident (as a new condition instead of acknowledging the existence of a pre-existing condition).

Source: Analyzing Medical Records, Marguerite Barbacci, BSN, RNC, LNCC and Patricia Iyer, MSN, RN, LNCC in Patricia Iyer and Barbara Levin, Medical Legal Aspects of Medical Records, Second Edition, 2010, Lawyers and Judges Publishing

The subject of head injuries associated with sports is in the news. A new study found high school-age athletes are more likely than younger kids to have sports-related concussions, but the rate of such injuries in both groups is on the rise. From 1997 to 2007, emergency department visits for concussion in kids aged 8 to 13 playing organized sports doubled, and the number of visits increased by more than 200 percent in older teens, according to the report. In related news, the American Academy of Pediatrics has issued new guidelines on what to do about sports-related concussions, with advice for both parents and physicians. The study and guidelines are published online and in the September print issue of Pediatrics. See the table for recommendations of action. Parents should know that “no athlete should go back to play on the same day they have their concussion. We recommend athletes who have a concussion be evaluated by a medical professional before they return to play,” Dr. Halstead said. Concussions can result in intracerebral hemorrhage, cerebral edema, and permanent damage. Repeated concussions, such as those suffered by boxers, can be disabling.

Source: http://www.healthfinder.gov/news/newsstory.aspx?docID=642556

Med League has worked on a few cases involving school-related head injuries. This is what I recall about these cases. In the first case, the school nurse became a defendant when a child hit her head on the wall. The school nurse was not clear enough to the parents about the need to have the child checked in an ER instead of going home. The child suffered a catastrophic brain injury; the plaintiff won the case.

In the second case, a college student was hit in his head during a soccer game, passed out, and was taken to the infirmary where an orthopaedic surgeon and college nurse examined him. Although they both advised him to go to the ER, he refused and went back to his dorm. A day later his roommate found him unresponsive and took him to the hospital, where he was diagnosed with a catastrophic brain injury. The judge dismissed the case against the defendants during trial.

The value of head injury cases is largely dependent on the liability issues and the extent and permanency of the damages. School personnel will need to be familiar with these guidelines so they obtain the urgent medical attention needed after a concussion. A delay in recognizing the development of swelling or bleeding can lead to permanent injuries.

Patricia Iyer is president of Med League.

A new study shows that motorcycle owners in the United States are getting older. The researchers looked at injured motorcyclists aged 17 to 89 years in the National Trauma Databank invovled in crashes from 1996 to 2005. Age trends and injury patterns were assessed over time.

Injury Severity Score (ISS), length of stay (LOS), intensive care unit (ICU) use, comorbidities (other illnesses), complications, sdeath, injury patterns, helmet use, and alcohol use were compared for subjects 40 and older versus those younger than 40 years old.

There were 61,689 subjects included. Over the study period, the mean age increased from 33.9 to 39.1 years, and the proportion of subjects 40 years of age or older increased from 27.9 to 48.3 per cent. ISS, LOS, ICU LOS, and mortality were higher in the 40 years of age or older group. The rates of admission to the ICU (32.3 vs. 27.3%), pre-existing illnesses (20 vs. 9.7%), and complications (7.6 vs. 5.5%) were all higher in the 40 years of age and older group.

Motorcycle riders are getting older and more seriously injured

The average age of the injured motorcyclist is increasing. Older riders’ injuries appear more serious, and their hospital course is more likely to be challenged by illnesses and complications contributing to poorer outcomes. Motorcycle safety education and training initiatives should be expanded to specifically target older motorcyclists.

The Aging Road Warrior: National Trend toward Older Riders Impacts Outcome after Motorcycle Injury
Authors: Brown, Joshua B.; Bankey, Paul E.; Gorczyca, John T.; Cheng, Julius D.; Stassen, Nicole A.; Gestring, Mark L.

Source: The American Surgeon, Volume 76, Number 3, March 2010 , pp. 279-286(8)
Publisher: Southeastern Surgical Congress

The next time you see an older motorcyclist, give him or her a wider berth and be extra considerate. Think about the slowed reflexes in an older person and the higher risk of injury. If you ride cycles, check out the tips at this site for avoiding injury.

Failure to rescue is a big source of patient injury

Failure to rescue is a term that describes the outcome when a patient’s condition deteriorates before the changes are recognized and acted upon. Failure to rescue is a nursing-sensitive performance measure on the list of 15 identified by the National Quality Forum in 2004 to be collected by CMS (Centers for Medicare and Medicaid Services). A 2009 study performed by HealthGrades showed that patient safety incidents with the highest incidence rates were failure to rescue. There were 92.7 incidents (per 1,000 population). Starting June 1, 2010, CMS began collecting data about a facility’s failure to rescue rates.

The use of rapid response teams (RRTs) to provide timely rescue efforts in hospitals has gained momentum and popularity, although not all hospitals have them. The concept originated with a critical care nurse from New Zealand who recognized the need to bring resources to the bedside of a patient whose condition deteriorated before more serious events occurred. Without rapid response teams, nurses who recognize ominous changes in the status of their patients are forced to contact the attending physician and wait for a return call. Should an attending physician refuse to deal with or minimize the concerns of the nurse, the nurse has to use the chain of command within a facility – in effect, to go over the head of the attending physician with the assistance of nursing administration, to find a physician who will respond. This is a slow and difficult process.

RRTs have the capability of bypassing the attending physician to turn what can be a 2-3 hour long process into a 5-10 minute arrival to the patient’s bedside. The use of a team within a facility empowers the staff nurse, and provides a safety net for both the nurses and the patients. Implementation of RRTs has reduced cardiac arrests, deaths, the number of unexpected emergency admissions to ICU, and the length of a hospital admission for cardiac arrest survivors. RRTs build teamwork and spread knowledge and skills throughout the hospital. The goals of the team are to provide immediate detection and diagnosis, to treat patients early, and to mitigate harm by turning adverse events into “near misses”. The system is designed to protect the patient from further harm and to allow for recovery from possible medical errors and system deficiencies.

Is the RRT system working? A survey of 56 staff nurses identified the three categories of reasons for why the RRT was activated:

• The patient exhibited signs and symptoms that were either unexpected or significantly different from baseline.
• Despite the absence of objective data, the nurse had a “gut feeling” that “something was wrong.”
• The nurse was convinced that the patient needed immediate evaluation and was unable to get the treating physician to respond as the nurse thought necessary. This is what one nurse said:

“It’s during shift change so everybody’s calling and running and doing this and that, and we called the doctor and he said, ‘Well, she’s got a pulmonologist on the case, call them.’ He gave us nothing. No orders. No meds. No, no nothing. . . At that point we decided we’re not going to wait for anybody else, we’ll just call rapid response and get them down here.”

Consider this comment in comparison to the often slow process of obtaining medical attention when a facility does not have a RRT. In addition to the direct patient safety benefits of such teams, RRTs empowered nurses and gave them a sense of control over the patient situation, identified other processes negatively affecting patient safety, and improved communication and respect between disciplines, thereby raising job satisfaction.

Sources: Shapiro, S, Donaldson, N, and Scott, M. “Rapid response teams: seen through the eyes of the nurse”, AJN, June 2010, 110 (6), 28-34
www.healthgrades.com/media/dms/pdf/patientsafetyinamericanhospitalsstudy2009.pdf

Extracted from Patricia Iyer, Roots of Patient Injury, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition, in press.

negative first impressions sow seeds of discontent

Have you had the experience of approaching a receptionist desk in a doctor’s office and having difficulty getting attention? Have you felt like you were an intrusion on the conversations going on behind the desk?

Have you ever felt like a diagnosis instead of a patient? In August 1996, my husband had a colonoscopy that revealed a large colon cancer. He was sent with a requisition form directly to the x-ray department to have a barium enema. The requisition form’s diagnosis stated “colon CA”. I sat next to my stunned husband; we had only a few minutes to absorb the news of his diagnosis. There was a technician responsible for getting him into the waiting area of the radiology department. One of her colleague asked her if she was ready to go to lunch. She called out, “No, I have to do a CA patient now.” I felt like someone had punched me in the stomach as I now realized my husband was branded as a CA patient.

None of these first impressions are cause for a medical malpractice suit but they set up a climate. An opportunity for establishing a caring environment is lost. If any mistake is made that causes harm, there are no credits in the bank- no kindly feelings towards the healthcare provider.

I advised Sara to make two copies of her letter and go to the school to express her concern about what had happened with the teacher. She learned, to her gratitude, that there were many positive comments in her file. She had made positive first impressions on lots of other teachers. What started as a negative experience turned into an opportunity for her to become of aware of how highly others regarded her.

* name changed

Giving medical care on an airplane

Be sure to fly with any medication you might need on a an emergency basis- nitroglycerin, inhalers, and so on. The story below made me think of my Brazilian experience. She discusses the medical and legal aspects of rendering care on a plane.

One physician learns firsthand that you are never really off-duty: An emergency on a flight teaches a young doctor that she’s never off duty by Laura Syndman MD

I met Brent after he was dead.

Neighboring passengers later told me that he took one bite of his sandwich and then his head dropped back. It wasn’t until 10 minutes later, when his wife tried unsuccessfully to wake him, that anybody realized anything was wrong.

I was sitting in Business Class with my parents – a trip to France to celebrate my near-completion of my Intern year in Internal Medicine (just 2 weeks of night float still to go). About 15 minutes after passengers were allowed to unbuckle their seatbelts, a flight attendant ran to the front of the plane, grabbed an AED and raced back down the aisle to Coach.

I was sitting across the aisle from my father, who had 30+ years of medical experience under his belt in comparison to my 11.5 months. “Should we go back there?” I asked, but my father said they would call for a doctor if they needed one.

I decided to check it out anyway.

Behind the curtain was a scene I will never forget: a man lying in the aisle with his feet towards the front of the plane, one flight attendant doing mouth-to-mouth, one doing chest compressions and a third attaching the AED pads. I tapped the last flight attendant on the shoulder, “Do you need help? I’m a doctor.”

“We’re fine,” he said, which surprised me. I wasn’t expecting that. Granted, I was in baggy pants, sneakers and a hooded sweatshirt, but was it protocol to decline help from a physician in a medical emergency aboard an aircraft?

Read more at http://tinyurl.com/yes4cay