there are rules and then there are rules

Tuesday, June 19, 2018

According to commentators and purists, Phil Mickelson did something bad this weekend. He willfully broke one of the rules of golf to minimize that damager that an errant putt might have caused him. Not only did he break the written rule, but he also broke the intention of the rule book, and that is supposedly a mortal sin, whether playing in a tournament or having a leisurely round of golf with friends.

In medicine, rules are probably the lowest in the hierarchy of clinical decision making and taking action to care for a patient. Rules, guidelines and protocols are not the same. Clinical rules in medicine help measure potential for both good and bad outcomes. A rule is developed to help with guidance for a specific clinical situation and the doctor at the bedside needs to decide whether they are appropriate to use.

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The Canadian Head CT Rules help decide whether a scan is appropriate to perform in a patient with a head injury. If the patient meets all the criteria, then a scan may not be needed…but there are caveats. It has been validated for patients from age 16 to 65, and may not be used in the pediatric population. PECARN (the Pediatric Emergency Care Applied Research Network) has developed rules for head injury in that age group. But should a doc use the Canadian or PECARN rules for a 15-year-old football player who is 6 feet tall, weighs 200 pounds and looks like an adult? The rules of nine, help measure the body surface area when caring for burn victims and calculating how much skin has been burned. It needs to be modified for infants and children whose heads are larger compared to the rest of their body, and some studies suggest the rule doesn’t necessarily work for people heavier than 80 kg (176 lb.)

 

 

Guidelines are written from a clinical perspective to help guide the medical care of patients. Rules may be used to develop guidelines ort may be incorporated into them. The American Heart Association routinely publishes and updates guidelines on the steps to care from acute emergencies like heart attack and stroke to guidelines on controlling chronic conditions like high blood pressure and high cholesterol. But there may be completing guidelines for the same situation and it is up to the doctor and the patient to decide what might be the best treatment strategy to consider.

  • The American Academy of Family Physicians and the American Urological Association sometimes spar about the use of PSA, a blood test to screen for prostate cancer.
  • For cancer patients who develop blood clots, treatment options recommended by the American College of Chest Physicians and the National Comprehensive Cancer Network differ. One isn’t right or wrong; both are out there.

Protocols are rigid. They are a recipe with specific steps that need to be taken when caring for a patient. Often, they are provided by a medical provider to allow others to care for patients. Imagine EMTs or paramedics caring for patients at the side of the road or nurses working in an extended care or nursing facility.

So the sequence might look like this. A doctor caring for a burn patient would use the rule of nines to calculate the percent of the body that was burned. That percentage would be plugged into the Parkland formula to calculate, as a guideline, how much intravenous fluid that would be needed to rehydrated the patient and the hospital protocol would require that all major burn patients be transported to a burn unit for further care.

The art of medicine is to keep up with the rules, guidelines and protocols and understand that they are ever changing. There may be times when it is appropriate to deviate from the mainstream recommendations when the individual patient may benefit. The standard line is that guidelines and protocols work until they don’t. In that way, Phil Mickelson and the medical community have found common ground. Rules can be bent or broken when the goal is to maximize benefit.

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wrist dislocation

Tuesday, September 12, 2017

One would think that some injuries are easier to diagnose than others. Broken bones and dislocated joints seem like prime examples of no-brainer injuries. There should be some major deformity or at least the x-rays would show the damage. One would think, wouldn’t one. But some parts of the body hide damage well and that brings us to the sad injury of David Johnson, running back for the Arizona Cardinals.

In the third quarter of the season opener, Mr. Johnson was tackled and landed on an outstretched hand. He immediately grabbed his wrist and went to the sideline. Initial exam by the medical staff allowed him to return to the game, but on the next play, he had trouble hanging onto the ball, fumbled it and was done for the day. X-rays were done and the diagnosis was a sprained wrist. Only hours later was the final diagnosis made of a dislocated wrist. Welcome to the world of medical uncertainty.

The wrist is a complicated joint. It is made up of the radius and ulna, (the bones of the forearm) and eight carpal bones aligned in two rows. Most doctors aside from orthopedic surgeons cannot name these bones without looking up an anatomy diagram.

Bones of the Wrist

They are held in place by a complex system of ligaments: interosseous (between the bones), volar (palm) side and the dorsal (back). The dorsal ligaments are weaker than the volar, so falling on an outstretched hand can potentially cause the backside of the wrist to collapse, sometimes fracturing the scaphoid bone and sometimes dislocating either the lunate by itself or the capitate bone from where it rests on the lunate. The specific type of dislocation isn’t as important as appreciating that even with bones out of place, the diagnosis can be easily missed on physical exam and sometimes on plain x-ray.

Scaphoid Fracture

 

Wrist Dislocations

People fall on their hands all the time and most often, there is little damage done, except for a skinned palm and bruised pride. But if there is greater force applied like in football or a fall from height, major damage can occur. However, the initial exam can be pretty unexciting. There may perhaps be a little swelling and tenderness on the back of the wrist and perhaps a little tingling of the index and middle fingers if the median nerve is irritated. Otherwise, people may ignore the injury and seek medical care only after developing chronic wrist pain and weakness.

The problem arises when plain x-rays are normal or perhaps misinterpreted, since evidence for a scaphoid fracture or dislocation may be very subtle or not there at all. Based on mechanism of injury, physical exam and care provider gestalt, the diagnosis may be suspected and then confirmed by CT scan or MRI.

If the diagnosis is made in the acute phase, attempts at reducing the dislocation can be made at the bedside, but often these fail and the patient is taken to the operating room where an open reduction and pinning of the bones occurs. Fortunately, there is a pretty big window of a couple of weeks to make the diagnosis and treat the injury. For many, return to play occurs relatively quickly, once all is healed, but that time frame is measured in months. However, there are complications to this injury and they include, decreased wrist range of motion, decreased power in the hand, carpal tunnel syndrome from medical nerve inflammation and failure of the scaphoid or capitate bone to heal (avascular necrosis).

From media reports, it’s not quite clear what happened to Mr. Johnson. A wrist dislocation is a non-specific term and may refer to a combination of many injuries or just an isolated one. It is reasonable for him to seek second opinions regarding treatment, but this is bread and butter work for most orthopedic surgeons, especially those who specialize in hand injuries. The big deal is getting the diagnosis made in the first place.

 

Images: learningradiography.com

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