NEXUS Criteria... Am I Missing Something?

[Kris1]

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So at my hospital trauma surgery is responsible for clearing the c-spine. The last few times that I have wanted to remove the c-collar after a CT reveals no fractures/dislocations, I have had significant push-back from trauma because there are other distracting injuries. I thought (and an Up-To-Date search confirmed) that a normal CT excludes 99.3% of fractures/dislocations and if it is normal then the c-collar can be removed despite distracting injuries. The NEXUS criteria, as I understand it, simply uses criteria to determine if radiography is needed, not whether the c-spine can be cleared or not in the presence of normal imaging. Am I correct or is there more to it than this?

 

[kungfufishing]

This sounds like the criteria are being misunderstood - nexus is designed to help with determining which patients to image.

If they are intoxicated, the water is a little murkier because a CT of Cspine does not show everything, but this is another discussion altogether.

 

[xaelia]

Just a quick point of contention: NEXUS does not tell you when imaging is required, it is a decision-support instrument that helps enable you to not miss significant c-spine pathology when choosing not to image. Essentially same application, but semantics.

NEXUS has nothing to do with removal of c-collar after imaging. I think what your trauma surgeons are concerned about is whether you can properly assess for neurologic deficit despite lacking evidence of bony injury when some other significant trauma is present. Your trauma surgeons probably also had a journal club with one of the recent articles where a bunch of ICU trauma patients with negative CTs went for MRIs while still critically ill and intubated - and they found some missed pathology.

Of course, the next logical step would be to discuss the literature describing the adverse effects of wearing a c-collar for an extended period.

And also the evidence behind how well a c-collar functions to protect secondary cord injury in a patient with c-spine bony or ligamentous injury.

 

[deleted65604]

If we lived in a sane world, a 0.7% miss rate would be acceptable. Alas, we don't.

My hospital had a missed ligamentous injury after a normal c-spine CT in a patient that was all banged up. The orthopedic surgeon was on the case, and realized a couple days out that there was some neurologic deficits and an MRI revealed an unstable ligamentous injury. If patients have fractured extremities, can't walk, are in extreme pain, and on high dose narcotic medications, how are you going to do a complete neuro exam? Would finding the injury earlier have changed the outcome? Doubtful.

I like the point about c-spine immobilization with c-collar. Do we really think that we are going to injure the spinal cord by a minor shift of the head? Compare this motion to the forces from original injury involving thousands of lbs of force and sudden, extreme displacement. Its like urinating in the ocean.

A conservative approach is to continue c-spine immobilization until more critical issues have been dealt with and MRI those patients who have abnormal mental status, severe symptoms, or severe pain on ROM.

One of my attendings in residency was sued after an intoxicated patient dove into a shallow pool and broke his neck. He was backboarded and c-collared on scene, c-collar continued in the ER, and log-rolled off back-board. The injury was promptly suspected, imaged and found and patient admitted to hospital in a c-collar. Reason for litigation? Inadequate c-spine immobilization resulting in neurologic deficits. My attending won the case, but spent thousands on legal fees.

Morals of the story
1. Patients love to blame their problems on doctors. Even drunk ******s who dive into shallow pools, breaking their own necks don't see hypocrisy in suing a doctor for their injuries.
2. You get sued, even when you do the right thing. We are expected to do EXTRAORDINARY things. (I'm talking Harry Potter-type wand-waving and "REPARO!" spells)
3. If your patient has a ligamentous injury that is found later with resultant neurologic deficits, they will blame you for not finding it sooner.

 

[Venko]

...(I'm talking Harry Potter-type wand-waving and "REPARO!" spells)...

My wand is from Welch Allyn, I highly recommend it because "Admit-tio!" makes the stagnant patients disappear upstairs!

 

[xaelia]

I like the point about c-spine immobilization with c-collar. Do we really think that we are going to injure the spinal cord by a minor shift of the head

As every ED physician can probably vividly imagine, it would be a rather hysterical study to evaluate how well those out-of-hospital c-collars actually work for their stated purpose. Little old ladies with the Philadelphia collar up to their nose, 2 year olds running through the halls, etc. Just take everyone with a negative CT and no neuro deficit, and before the ED MD takes the collar off, just have them try a few basic ROM movements and measure the hysterically inadequate inline stabilization.

Add to the list of medical interventions that sounds good in theory - futile in practice.

 

[southerndoc]

My attending won the case, but spent thousands on legal fees.

Not to hijack the thread, but in a case like this, I would sue the patient and lawyer for legal malpractice and frivolous lawsuits in order to recover lost time and expenses.

Luckily my state has a gross negligence clause.

 

[deleted65604]

One of my colleagues was recently sued after a patient presented to him after a finger injury. The middle phalange was crushed into 5 different pieces, with jagged, open wounds to the finger and some tissue loss. My colleague blocked the finger, irrigated the wound, placed her on antibiotics, contacted the local hand-surgeon, and set up an appointment the next day to for the patient to be seen. The patient went the next day and the hand surgeon recommended amputation of the finger. The patient refused and left without being treated. She presented to a different orthopedic surgeon a few days after that when the wound became infected, requiring amputation. The doctor (who wasn't a hand surgeon) said he could have saved her finger if he had seen her initially, but since it was infected, he needed to amputate it.

My colleague is being sued because she claims that he looked at her wound, exclaimed, "That ain't good", removed a piece of bone from the wound, inspected the shard of bone, and then shoved it back in the wound. Of course, my colleague claims that is ludicrous and I believe he wouldn't do that.

Moral of the story:
1. Patients lie. You will hear your own words twisted into monstrous things. You will watch your actions twisted into portrayals, which only vaguely resemble your memories.

It is IMPERITIVE that we have malpractice reform to protect us. Anybody who says different is a traitor to the cause, and should be run out of the practice of medicine.

We MUST be tried by a jury of our peers (doctors, not lay-people). Only then can these ludicrous claims be sorted out by people who can look at the literature and look at the facts of the case and make a good decision.

We MUST be innocent until proven guilty like the rest of the people in the criminal justice system. Currently, the standard is that we are guilty if it is probable, not beyond a shadow of a doubt. Suspected murderers are treated better than us in court.

Court costs for the winning case MUST be paid be the loser, to discourage the lottery-like mentality that lawyers currently have in litigation. Where is the downside to suing? The vast majority of the time, the opposition just folds and settles for large sums of money and the litigators, client and lawyer, become filthy rich, even when no malpractice was committed.

 

[pagemmapants]

Luckily my state has a gross negligence clause.

Which state is that and are you hiring? 😉