This is the 68th #WILTW
An ambulance has arrived at the Emergency Department with a mother and her child.
The mother looks anxious but her 3-year-old is happily playing with a glove ballon given to her by the paramedic. They have both been hit by a car at an unknown speed. The car left the scene but eye-witnesses are sure the car was going at least 20 miles per hour. Mother recalls hitting the bonnet of the car and the road. She doesn’t think she was knocked out but can’t be sure. She remembers being so shocked that she just lay on the floor amazed she was still alive.
You do a thorough examination but apart from minor abrasions there appear to be no serious injuries.
Their physiological parameters are normal.
Clearly a period of observation is needed. Is anything else? The mechanism of injuries sounds very dangerous. Should you do a head scan? Do they need x-rays?
What happens if you are then are shown this video of the event:
https://www.youtube.com/watch?v=efNhIaZl2rE
Does, and should this, change what you do?
CCTV has been around for a while but increasing use of mobile devices has enabled recordings of clinical events to be frequently available to health care professionals. In the field of neurology this has been incredibly useful and while there are concerns about quality (and disagreement between neurologists themselves about what the videos show!) some medical institutions have embraced this technological revolution.
In the field of trauma this has added complexity however. Whether they realise it or not, doctors are commonly using Bayesian methods. (Very) basically patients they see have a certain risk of illness, tests are then performed which increase or decrease that risk allowing doctors to make a decision on whether to treat or not.
You may see a patient who from appearance and the history has a low risk of having a particular injury or illness. The test results you are looking for would have to be striking for you to act on them and you might not even consider doing tests at all. But what if you had new information which changed your perception of risk, Would you be comfortable doing nothing on the child and her mother having seen the video? Technically nothing has really changed as before seeing the video you had already mapped out in your head the likely outcomes. In the era prior to CCTV and mobile phones you would have had none of this dramatic footage to guide your decsision making so how should this effect your judgement?
This week I was given a similar diagnostic connudrum. The patient suffered no harm but it is ever more likely we will have our normal practice challenged by information we would never previously had access to. It is important we do not start becoming defensive practitioners but at the same time patient safety is paramount. What has become most obvious to me is the communication challenge this will present. As a parent, carer or family member you may have difficulty understanding how you can not do any tests if you have seen footage as dramatic as that above. In this new age communicating risks and benefits based, not just on reported history and examination, but visual recordings of actual events will become part of a health care professionals skill set.
What did you learn this week? #WILTW
(For those receiving this blog via e-mail please note there is an embeded video which you will need to click onto the website to see)
Fantastic post. A picture can tell a thousand words and taking photos at the scene of an incident is a great way to convey what was seen from the pre-hospital point of view to the ED. Many uses for technology to aid us in what we do.
Very interesting post. One that requires a lot of thought and careful management for future as technology advances and becomes more and more intrusive (probably not the best word) in the field of emergency health care. Very interesting slide show also on Bayesian Theroem 🙂
The current evidence base is based on the physical presentation of patients and the history that has been communicated from paramedics. If we react to new history elements we may find we are straying from the applicability of the evidence. However, logic suggests that if the history confirms to us that the mechanism was indeed consistent with major trauma we must take this into account.
Interestingly, there would be many injuries missed if we didn’t do any tests of patients with this presentation, regardless of whether we saw the video or not; for example see http://archsurg.jamanetwork.com/article.aspx?articleid=398427. This shows there is an 18% change in treatment having done whole body imaging in this population.
Thanks Dr. Greenway – never seen that paper. Certainly makes you think!
I suppose I would argue there are many things we don’t investigate and so don’t know what the end result would be. I have always harboured a desire to run a CRP on every patient presenting to a Children’s ED over a weekend. I am sure would show such a wide range of values you’d never want to take one again 🙂