Apr 27, 2021

WTF! They're Living People, For Cryin' Out Loud: The Sad Saga of Futile Trauma Transfers


I subscribe to everything related to health and stroke, and this article amazed even me, who rarely gets shocked anymore. 

This article by Jenna Basset appeared in General Surgery News: Futile Trauma Transfers Uncommon but Costly. The reprint follows here; rather blasting comments appear at the end. 

Despite making up less than 2% of trauma transfers, unsalvageable patients present a significant cost burden to the health care system, researchers report. 

Researchers at the University of Kansas Medical Center (KUMC) investigated the rates and costs of futile transfers within their organization between June 2017 and June 2019. Futility was defined as a patient who had a stay that was no more than 48 hours that resulted in death, implementation of hospice care or discharge with no major operative, endoscopic or radiological intervention. 

Within the study period, there were 1,241 trauma transfers. Among the 407 trauma transfers with hospitalization time less than 48 hours, 18 patients (1.5% of the study population) were deemed futile. In both the futile and nonfutile groups, the majority of patients were transferred for traumatic brain injury and the need for neurosurgical consultation or intervention. 

The researchers evaluated injury severity among transferred patients using the Injury Severity Score (Iss), a validated score that correlates with morbidity, mortality and hospitalization time after trauma. Scores above 15 indicate severe injury. image Futile transfers were older, with more severe injuries as indicated by a median Iss of 21 versus 8 in nonfutile patients. 

Specifically, futile patients had more severe injuries to the head and torso. The median cost of treating futile patients was $56,396, and the total cost to the health care system exceeded $1.7 million during the two-year study period. 

The authors estimated that elimination of futile transfers would result in a cost savings of over $27 million annually in the United States. 

“Our study clearly has limitations in that our data represents the retrospective experience of a single institution serving a large network of rural referral facilities,” explained presenting author Craig Follette, DO, a general surgery resident at KUMC, in Kansas City. “The data may not be able to be generalized to other trauma networks but could be compared to similar regional networks.” 

Dr. Follette also added that the study definition of futile was conservative, which may affect study conclusions, and the data do not show the intricacies of what occurs in the period surrounding a trauma transfer. 

“It is possible that patients received therapies not available at referral centers, although, in our experience, this would be extremely unlikely in the absence of ongoing consultant care.” 

To optimize trauma transfer, the researchers propose a new trauma transfer paradigm that incorporates a telehealth support component that could be used to extend specialist support to critical access hospitals. 

“While beyond the scope of this paper, we believe that this future state will involve enhanced means of communication through telehealth/tele-trauma, and the overall sharing of Level I trauma center expertise beyond the walls of the center itself,” Dr. Follette said. “I believe the next step is collaboration with other centers in multicenter studies to truly define this special patient population and guide further resource utilization region by region.” 

The authors concluded that additional work is needed to avoid futile care and ensure appropriate allocation of health care resources to patients who will benefit. 
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Let me tell a story to set up my comments. A college friend 50 years ago (this is a whopper of a story accounting for why I remember it) told me that her husband's grandmother was dying and was in hospice at the facility in Florida. He lived in Pennsylvania, but his brother was a Florida resident. The two of them came up with a plan. Since grandma was at death's door and lived in a ritzy apartment, her hubby took a car trip and a huge trailer to Florida, met his brother, and went to Grandma's apartment to divvy up whatever appealed most to each of them. Even the marble floor was chipped away carefully. 

After they were done, with the large apartment empty and satisfied with their "inheritance," her hubby took the car and the trailer back to Pennsylvania where he unloaded all the wonderful contents. He placed them in his gorgeous house, even the marble floor.

One problem: their grandmother lived, survived hospice care, and stayed in the hospital until she strong enough to return. Her hubby took all the contents back to Florida, even the marble floor. His brother did the same, too, and "restored" her apartment with the same things two weeks after they had taken them. 

Lesson: Just because the person appears "futile," the life is over when it's over, not a second before. 

"Futility was defined as a patient who had a stay that was no more than 48 hours that resulted in death, implementation of hospice care or discharge with no major operative, endoscopic or radiological intervention" and is pointless. 

If that were the case, I wouldn't be here today because "no major operative, endoscopic or radiological intervention" in under 48 hours was done. The doctor had enough compassion to wait, and that waiting saved me. 

Every hospital should try, by any means and no time factor present, to keep the patient alive. That person is someone's parent or sibling or cousin or friend or colleague. 

Yogi Berra, celebrated baseball played and New York Yankees manager, is said to have originated the phrase "The game isn't over till it's over."

Exactly my point, Yogi.  

Apr 14, 2021

Young Multiple-Stroke Patient Gives Parent PTSD







 Count 'em, folks. F-I-V-E!

This post all started from an email I received anonymously:

I'm the parent/caretaker of a 9yrs old pediatric stroke survivor. I have been suffering from PTSD since his first event. He is now 14yrs, has had 5 strokes to date and I call him a'thriver'. But I just never know when...the...next...might come? My son's condition will not 'get better' or just 'go away'. He will never 'get over it' and as a result, I've had to put my constant fear in my pocket and just keep going. I'd like to know more about studies done on 'parents' of pediatric stroke survivors and how common the PTSD experience is within this group.

That being said, you are not alone. Pediatric cancer, tumors, severe injuries,Type 1 diabetes, epilepsy, or other neurological disorders can cause post-traumatic stress. Symptoms may include:reliving the experience, avoiding remindersof the event or condition, feeling numb or detached from others, anxiety, difficulty concentrating and being constantly on the lookout for danger.

Most Notable: Riley Children's Health from ndiana University Health says an estimated 10-20% of parents with medically fragile children meet the clinical criteria for PTSD.

The triggers may be different, but the results can include hypervigilance, withdrawal, anger and guilt.

From the National Institutes of Health: "Despite evidence suggesting that rates of PTSD in parents decline over time, a significant proportion of parents continue to suffer clinically significant levels of distress in the long-term.

"It remains difficult to characterise the trajectory of parent distress over time for a number of reasons. Past research has mainly examined a single illness group, and many studies use different scoring tools and methods, making it difficult to determine trajectories over time, the predictors of functioning at different phases of the model, and whether illness factors or the type of illness contributes to different outcomes."

The Take a Breath Cohort Study from the Royal Children’s Hospital, Melbourne, Australia, is underway to determine how significant this problem is across different illness groups, and the "extent to which there is spontaneous resolution of symptoms requiring no further intervention, or to what extent early intervention is warranted."

The link, the study confirms, between parent psychological distress and notable childhood illness has phenomenal effects for pediatric healthcare and parental PTSD.

The study goes on to say, "A greater understanding of parent distress reactions and their impact will also assist in the allocation of resources to address this problem, with those potential resources ranging from basic psycho-education, to more involved psychological approaches (e.g.interventions based on cognitive behavioural therapy or acceptance and commitment therapy) to involvement with psychiatry can provide a map for treatments that are preventative, innovative, and targeted to the true needs of the child, family, and healthcare system.”

Kidshealth.org says, "Studies show that people with PTSD often have atypical levels of key hormones involved in the stress response.

"For instance, research has shown that they have lower-than-normal cortisol levels and higher-than-normal epinephrine and norepinephrine levels, all of which play a big role in the body's 'fight-or-flight' reaction to sudden stress. (It's known as 'fight or flight' because that's exactly what the body is preparing itself to do — to either fight off the danger or run from it.)"

https://blackbearrehab.com:

  • Flashbacks can be scary to children and to parents as well.
  • Depression, anxiety may arise.
  • Hypervigilance may startle children.
  • PTSD often leads to substance abuse.

So yes, you are not alone with PTSD and an ill child. To my readers, and to Anonymous, seek medical advice if you suspect PTSD, and you may be entitled to medical and other support. You have my best wishes in this unimaginable struggle.

Apr 10, 2021

Do You Think Stress Alone Can Cause a Stroke?


My stroke was inherited, a Protein S deficiency which causes blood clots. And you probably know the rest and the reason this blog came about.

I've been quite stressed lately because I've been inside, no thanks to the pandemic, and I thought, bordering on overthinking, would stress give a person a stroke? Or a second stroke? 

Most people already understand that high blood pressure, high cholesterol, and smoking increase a person’s risk of stroke. But without those negative situations, can plain old stress cause a stroke? Unfortunately, studies have shown so, all around the world. Just a sampling....

The Copenhagen City Heart Study, who asked people about their stress levels and analyzed their health, concludes, “Self-reported high-stress intensity and weekly stress were associated with a higher risk of fatal stroke compared with no stress.”

Researcher Ana Maria Garcia, MD, of the Hospital Clinico Universitario San Carlos in Madrid, says, “Our findings indicate that people can lower their stroke risk by attempting to reduce the stress in their lives. The study included 150 people who'd had strokes and 300 randomly selected people who had not had strokes. The average age of the participants was 54, which is much younger than the typical stroke patient."

Garcia says that studying the correlation of stress on stroke was easier in younger people who had strokes because they were less likely to have health issues like high blood pressure that have been linked to stroke.

 
The American Academy of Neurology  says that anger and other negative emotions may be triggers for ischemic stroke. The study found that people who had strokes were more likely to have experienced anger or negative emotions in the two hours prior to the stroke than at the same time the day before the stroke. They were also more certain to have reacted fast to a surprising event, such as arising at night  suddenly after hearing a child tumble and cry or standing up from a chair in haste after witnessing a tumultuous noise.

Stress causes the brain to release certain substances that adapt the body to confront a risk. They are known as chemicals: cortisol which prompts the body to retain water, salt, and sugar to help keep blood pressure on the up side and, in most cases, allows the body has extra power to function, and epinephrine which increases heart rate and blood pressure to distribute blood to the organs.

Flint Rehab says, "Persistent high cortisol levels increase salt retention, which leads to hypertension (high blood pressure) and high cholesterol levels. High cholesterol and blood pressure in turn both increase your risk of stroke.  In addition, high blood pressure from chronic stress can increase the risk of a hemorrhagic stroke, which occurs when blood vessels rupture."

It's the chronic stress, not once-in-a-while stress, that can cause a stroke. Here is a list of many signs that you're in a stressful situation:

  • Chest pain
  • Sudden headaches
  • Low energy
  • Stomach problems such as diarrhea
  • Tense muscles
  • Shaking and/or cold sweaty hands
  • Insomnia
  • Dry mouth and difficulty swallowing
Stress can also cause emotional and cognitive issues such as the onslaught of frustration regularly  or constant memory loss. Since there is a strong tie between stress and stroke, it’s important to find ways to incorporate lifestyle changes such as eating a healthy diet, doing meaningful exercises, and practicing meditation. 

But all that said, lousy inherited genes like I have? Unfortunately, there's no help for that. BAM!!! Just like so.