Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma. Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include: Analysis of best available data Use of best available judgement Gathering of different opinions An understanding that you won’t always make the right decision To document the 'crap' out of it! And to remember you’ll never know what you prevented from not occurring. Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases). Touching on the processes designed to prevent missed injuries such as; Territory Trauma Survey Roles of clinical decision rules To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks). Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces. Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers. Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.

1. Trauma is Risky Business
Deb Stein, MD, MPH

2. Trauma is Risky
Business??

3. Risk to whom?

4. The injured patient…
• Lots of risk here
– Death
– Morbidity from injury
– Complications
– Iatrogenic morbidity
– Pain
– Psychological issues

6. Risk vs. Benefit…
• The “healthy
people doctors”
don't have this
problem

7. A patient…
• 21 year old male S/P MCC
• GCS 5 on admission

8. A patient…
• 22 year old male S/P MVC

9. A patient…
• 84 year old female S/P MVC
• Hemiplegic on admission with
facial droop
• CT negative except “subacute” T8
fracture

10. There are no right
answers…
• Use best available data
• Use best available judgement
• “I didn’t shoot ‘um”
• Document the crap out of it
• You never know what you prevented…

11. Missed Injuries
• Missed injury rates range from
1.3% to 39%
• Vast majority are due to human
error
– clinical error in patient assessment
– misinterpretation of the radiologic
findings
– lack of appropriate radiographic
studies Pfeifer R, Pape HC. Patient Saf Surg 2008;23:2–20
Clarke DL, et al. World J Surg 2008;32:1176-1182

12. A phone call…
• Whadda u gonna do ‘bout it…

13. Missed Injuries -
Prevention
• Tertiary Trauma Survey designed to
prevent/minimized missed injuries
Enderson BL, et al. J Trauma 1990;30:666–9.

14. Missed Injuries -
Prevention
• Role of clinical decision rules
Hoffman JR. NEJM. 2000;343:94-9

15. • Whole body CT –
“panscanning”
– High accuracy for a wide
range of injuries
– Low missed injury rate
– Can be performed
rapidly
• Not for “free”
Missed Injuries -
Prevention
Salim A. et al Arch Surg. 2006 ;141(5):468-73
Reiger J Trauma. 2009;66(3):648-57
Leidner B, Beckman MO Emerg Rad 2001; 8(1):20-28

16. WBCT
• FIRST (French
Intensive Care
Recorded in
Severe Trauma)
• Multicenter cohort
study
Yeguiayan et al. Critical Care 2012 ;6:R101

17. WBCT
• 11 trials enrolling 26,371 patients
were analyzed
• WBCT was associated with lower
mortality rate and a shorter stay in
the ED
• There was no effect on LOS
• Patients in the WBCT group had a
longer duration of mechanical
ventilation and higher incidence of
MODS/MOF
Jiang L, et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014; 22:54

18. Missed Injuries -
Impact
• Reality is…
– Most injuries are low severity
– Rarely result in death (but not always)
– May result in long term morbidity though
• One autopsy study revealed that 6.5%
of deaths were attributable to missed or
delayed injury diagnosis
Keijzers et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:77
Giannakopoulos GF, et al.. Injury 2011;doi:10.1016/j.injury.2011.07.012
Enderson BL, et al. J Trauma 1990;30:666–9. Miller PR, et al. J Trauma. 2002;53:238-244.
Cooper DJ, Ackland HM. Crit Care Resusc 2005;7:181-184.
Gedeborg R, et al. Crit Care Med 2009;37:449-455.
Pfeifer R, Pape HC. Patient Safety in Surgery 2008;2:20.

19. Missed injuries
• Some risk to the patient…
• Lots of potential risk to the
providers

21. Perceptions
• Trauma care providers get sued
“all the time”
• Trauma care providers get sued
more than other health care
providers

22. Perceptions
• 39% of the total sample of surgeons
who responded would prefer not to
treat any trauma patients
• These surgeons agreed strongly with
the statements that “these patients
require a greater time commitment and
pose an increased medico legal risk”
Esposito T, et al. Archives of Surgery. 1991;126:292-297.

23. Lawsuits
Kane CK. Medical Liability Claim Frequency: A 2007-2008 Snapshot of Physicians. AMA. 2010

24. Lawsuits
• The proportion of
physicians facing a claim
each year ranged from
– 19.1% in neurosurgery
– 14.5% in orthopedic surgery
– 15.3% in general surgery
– 7.9% in emergency medicine
• By the age of 65 years
– 99% of physicians in high-risk
specialties
Jena AB, et al. N Engl J Med. 2011;365(7):629-636.

25. Lawsuits - Surgeons
• Over 7,000 respondents
• The data showed that 25% respondents experienced a
malpractice action within 24 months prior to the survey
• Compared with surgeons not involved in a malpractice
lawsuit, those involved were more likely to be (p < 0.0001
for all)
– Younger
– Male
– Work more hours per week
– Have frequent night call
Balch CM, et al. JACS. 2011;213(5): 657-667

26. Lawsuits
• Trauma has a significantly higher rate of
indemnity payment per admission and per
hospital day.
• More TS (20.0% vs. 3.15%) were at moderate
(score 50-69) or at high risk (score >70)
– (7.27% vs. 2.57%; p < 0.001)
Morris JA, et al. Ann Surg. 2003;237:844–852
Mukherjee K, et al. Journal of Trauma . 2010:69:549-554

27. Lawsuits
• Why?
– Trauma patient expectations are the most difficult to
manage since there is no preinjury physician-patient
relationship
– Families’ lack of understanding of the disease process
– Anger that is frequently transferred from the
perpetrator to the care provider
Morris JA, et al. Ann Surg. 2003;237:844–852
Mukherjee K, et al. Journal of Trauma . 2010:69:549-554

28. Lawsuits
• Another opinion:
–No increased risk
of litigation when
caring for trauma
patients
Gross et al. Ann Surg 2005;241: 969–977

29. Lawsuits
• “Although there is no preinjury physician patient
relationship in [trauma] in most cases the gravity of
the situation is obvious to both patients and care
providers, and in most cases the bad outcomes are
reasonably easy to predict given the patient’s initial
anatomic injuries and physiologic condition.”
• “Expectations can be assessed by an initial
conversation between the senior trauma surgeon
and the patient’s family shortly after admission to
the hospital.”
Gross et al. Ann Surg 2005;241: 969–977

31. Preventing Lawsuits
Gross et al. Ann Surg 2005;241: 969–977
COT-ACS. Resources for Optimal Care of the Injured Patient, 1998.
ACS-COT. Trauma Performance Improvement: A reference manual.
http://www.facs.org.trauma/publications/manual.pdf

32. Effect of litigation on
health care providers
• Malpractice lawsuits were
strongly and independently
linked to surgeon depression
and career burnout
• Surgeons who experienced a
recent malpractice lawsuit
reported less career
satisfaction and were less
likely to recommend a surgical
or medical career to their
children or others
Balch CM, et al. JACS. 2011;213(5): 657-667

33. Are we protecting
ourselves from risk and
harm?

34. Personal Harm
• The CDC estimates that each year 385,000
needlesticks and other sharps-related injuries
are sustained by hospital-based healthcare
personnel
– An average of 1,000 sharps injuries per day
• Surveys of healthcare personnel indicate that
50% or more do not report their occupational
percutaneous injuries

35. NSIs
• Of the estimated 385,000 needle-stick injuries,
23% occur in surgical settings
• While needlestick injury rates have been
decreasing among non-surgical health care
providers, this has not been the case among
those who work in surgical settings
Jagger J, et al. JACS. 2010;210:496-502.
Jagger J, et al. Association of periOperative Registered Nurses Journal.
1998;67(5):979-96.

38. Can we “crack the
chest?”
• The risk of exposure and lethal infection to medical personnel during ERT is
considerable.
• Of 112 patients who underwent ERT, the overall survival rate was 1.8%
Esposito TJ, et al. J Trauma. 1991;31(7):881-5

39. Universal Precautions
• Study used videotapes of trauma cases seen at an urban
Level I trauma center
• Observed 1 or more major breaks in 33.6% of 304
invasive procedures
• Large and statistically significant variations were seen in
use rates of barrier precautions among different groups of
personnel
– surgery residents were most likely to use precautions
– attending surgeons were least likely
Evanoff B, et al. Ann Emerg Med. 1999;33:160-165

41. Personal Safety
• In healthcare, and particularly in
nursing, violence remains
prevalent
• Australian studies reveal that
patient-related violence is
experienced by the majority of
emergency nurses
Pich J, et al. Nurs Health Sci 2010; 12(2): 268–74.
Gilchrist H, et al. Australas Emerg Nurs J 2011; 14(1): 9–16.
Lyneham J. Aust J Adv Nurs 2000; 18(2): 8–17.

42. Personal Safety
Morphet, J. Australian Health Review, 2014, 38, 194–201

43. Personal Safety
• According to data from the U.S. Bureau of
Labor Statistics, the most common source of
nonfatal injuries and illnesses requiring days
away from work in the health care and social
assistance industry was assault on the
health care worker
Wolf LA, et al. J Emerg Nursing. 2014;40:305–310

44. Is your doctor burned out?
By Alexandra Sifferlin, TIME.com
Updated 3:44 PM ET, Tue August 28, 2012
Doctors are significantly more burned out than adults in the U.S. general population, according to a new study.
Story highlights
•Nearly half of U.S. doctors have at least one burnout symptom, a study finds
•Fatigue can erode professionalism and compromise quality of care
•Doctors are significantly more burned out than the general population
•Job burnout can strike workers in nearly any field, but a new study finds that doctors are at special risk.

46. Trauma is Risky
Business!!