decision making

Monday, February 9, 2015

The press release was very black and white. Blake Griffin, star of the LA Clippers, requires surgery for an infected elbow. If only medicine was so cut and dry and just one option was proven to be effective. But in the real world of caring for patients, this short story does not do justice to the sometimes complex treatment alternatives that might be appropriate when caring for an injury or illness. Alternative treatment approaches mean that the physician and patient may have to come to a consensus about care, even when the medical literature and research cannot give much guidance. This may be the lesson to be learned from Griffin’s elbow short story.

elbow-bursa

The olecranon is the point of the elbow and there is a small bursa or sac that protects the skin from rubbing across that pointy bone edge with every bend of the elbow. On occasion, the bursa can become inflamed, either because of one acute blow or because repeated falls, resulting in bursitis (itis=inflammation). There is pain and swelling and the diagnosis is pretty easy because the swollen sac appears as a small knob overlying the elbow. Usually, it resolves with PRICE (protection, rest, ice, compression and elevation). Competitive athletes may not be allowed the time to rest and injecting the bursa with steroid may help with healing.

Sometimes the bursa becomes infected. Most commonly, the skin overlying the injury is damaged due to a laceration or abrasion, but the infection may arrive in the elbow after traveling through the blood stream from another site. The infection may also be a complication of aspiration, when a needle is used to inject steroid. And this is where the Blake Griffin treatment discussion begins.

The research is confusing and does not come to a consensus. Some studies suggest that the best outcome for infected olecranon bursitis occurs with a prolonged course of antibiotics. Other studies suggest that immediate surgery is appropriate. Yet others recommend surgery only after antibiotics have been started or have failed to produce a cure. depending upon the researcher, those antibiotics might be recommended to be administered intravenously or by mouth, depending upon the severity of the infection.

The treatment successes are confusing. In mild infection, antibiotic therapy can fail from 10-30% of the time while sever bursitis has a failure rate up to 50%. When it comes to the research though, the definition of mild versus severe is not set in stone. The severity of an infected olecranon bursa is in the eye of the beholder; mild to moderate infection is described as having local, significant inflammation while severe infection will show intense bursitis. There are other associated symptoms to look for, but it’s tough to know how significant “significant” is and how intense “intense” might be.

Those who advocate surgery as the first treatment option point to the statistics that show recurrent infection that happens “only” 15% of the time when the infected bursa is removed. If surgery is considered, the use antibiotics don’t decrease the re-infection rate. The type of surgery is also open to debate, including whether to leave the skin open and allow healing to occur over time, or whether the skin should be closed immediately. There are some surgeons who advocate operating with an arthroscope to make the smallest cuts possible, while others suggest a wide incision as better choice.There are a variety of other combination treatment approaches using antibiotics by mouth or intravenously, in association with surgery that are touted, depending upon the individual situation and that is the crux of the matter.

Once upon a time, the practice of medicine was all about diagnosis and there were few options available when it came to treatment. Modern medicine now has many more tools to help establish a diagnosis and offer different ways to approach treatment. It is the physician’s responsibility to teach the patient and family about different options, their benefits and risk, and to come to consensus about which plan best fiuts a particular patient’s situation. That does not mean that the physician needs to take a back seat in the decision making and agree to do something that is harmful, but it does mean that the patient has some responsibility in what happens to their body.

Much goes into the decision that cannot be summarized by a story that proclaims that Blake Griffin needs surgery. The decision may rest on the facts of the case: there is the history of repeated needle aspirations of chronic bursitis, there is an infection that occurred after the most recent injection and there is the importance that he and his team are in the midst of a playoff race with his return to play vital for his team’s success.

Those same considerations exist for those who are not famous and don’t live their lives in the public eye.  The same discussion issues exist in treating a kid’s ear infection with or without antibiotics, choosing a cast or operation for a fracture or deciding to admit or send a chest pain patient home. Decisions happen every day in medicine and it’s up to the doctor to remember to educate and up to the patient to ask to be taught.

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it’s only a flesh wound

Monday, May 27, 2013

Hockey trainers make a living closing nicks and cuts, getting the blood to stop, so that the player can get back onto the ice without missing a shift. They do their job well in the public eye and the television camera loves the close up. What the spectator doesn’t appreciate is the wound care that happens in the locker room after the game. While a jagged scar may be a badge of honor, most people don’t appreciate seeing that scar every morning when they look in the mirror.

Repairing a laceration weds science and art to allow for a good looking scar while minimizing the risk of infection, preventing a wound from falling apart. Let’s begin with the first rule. The purpose of wound repair is to maintain function and prevent infection. The second rule is that a good looking scar cannot occur if the first rule is not followed. And the third rule is that there will always be a scar.

Regardless of the word used, whether it is cut, laceration or wound, they all describe a situation where the integrity of the skin has been compromised and the potential for infection is introduced. As well, critical structures beneath the skin are at risk for injury, and depending upon location can include tendons, arteries, nerves, and ducts. Repairing a laceration is all about balancing form and function. While a good cosmetic result is a nicety, a normally functioning body is a necessity.

The steps of repair have not changed since Louis Pasteur described germ theory as the cause of infection. Perhaps Dr. Harvey Cushing, the father of modern neurosurgery, said it best:  “Certainly, infections cannot be attributed to the intervention of the devil but must be laid at the surgeon’s door.”

Wounds need to be cleaned and explored before they can be repaired and the purpose of the repair needs to be remembered each time a patient presents with a laceration. Since all wounds will heal eventually over time, that purpose is to give a good looking scar.

  • Step 1. Know how the wound happened. A clean wound by a kitchen knife is approached differently than a burst wound in happens on a muddy football field.
  • Step 2. Examine the patient and understand anatomy. Know what structures lay beneath the skin and are at risk for damage. Know your patient. Those with diabetes or peripheral vascular disease may have a harder time healing wound and infection rates may increase.
  • Step 3. Anesthetize the wound so that it can be explored to its full depth and cleaned thoroughly.
  • Step 4. Take a deep breath. If all is well beneath the surface, the rest of the job is all about cosmetics. The wound will heal if it is clean, but even if washed out well, the risk of closing the skin and locking in a potential infection may be too high. Think animal bites and humans. It may be that wound repair stops here.
  • Step 5. If all is well, it’s time to close the wound. Whether it is steristrips, skin glue, staples or thread, the idea is to bring the edges of the skin together with as little tension as possible to minimize the scarring that will always occur.  Depending on the location and situation, one type of closure will be preferable to another. Skin glue can’t be used when hair is involved. Eyebrows are out, since shaving them is not an option; there is no guarantee that they well regrow. Steristrips don’t work well when the laceration is 90 degrees to the crease lines and are placed under stress when the body moves. Suture gives the most control and the size and type of thread used depends upon body location and sewer’s preference. Before the skin is closed, it is important to remember that, if needed, deep layers may need to be sewn together to decrease the amount of work that the stitches that hold the edges of the skin together need to do. The less tension on the skin, the better the scar.
  • Step 6. Keep the wound clean and take the stitches out as soon as feasible, again depending upon the location and situation. The face has great blood supply and heals quickly. Stitches are often removed in 4-5 days to prevent the stitches themselves from scarring causing the appearance of crosshatching or railroad tracks. Wounds across a joint take longer to heal since the skin is always moving.

The mechanics of wound repair are not difficult. Make certain that everything works and then wash the crap out of the wound to prevent infection. The art of wound repair is what takes practice and expertise. With enough experience, good cosmetic results are routine regardless if it is the family doctor, emergency physician or plastic surgeon holding the needle driver.

Watch the trainers on the bench. The tools that they use are saline (salt water) and gauze pads for cleaning and skin glue or steristrips to close the skin. Anything more needs to happen in the locker room or the ER. Their goal is a temporary fix to get the player back on the ice. The end game remains the same A good looking scar may yet happen but at a different place and at a different time.

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