How many times have I been asked by the trauma surgeons to see a trauma patient for respiratory failure? The reason for intubation and ventilatory support – being combative and non-cooperative.

Intubating, sedating and sometimes even paralyzing a combative patient is an established practice. Combative patients are dangerous to themselves and to the medical staff. Clinical and radiological evaluation of these patients is difficult as well. Asking “What is hurting, Sir” if the patient is kicking, screaming, biting and spitting is unlikely to yield any clinically useful information. Getting an extremely agitated patient to a CT scanner could be a great challenge.

Most of those patients end up on a ventilator only temporarily. Once the effects of alcohol and drugs that had been taken wears off the patient is taken off the ventilator. In some cases serious injuries could be found that would require extended ventilatory support.

Intubation or insertion of a breathing tube could be associated with complications. Especially when performed urgently and in the field conditions, the patient can experience hypoxemia (low oxygen level), aspiration of gastric contents into the lungs and damage to the vocal cords. Sedatives and paralytics used for intubation can interfere with the neurological exam and clinical evaluation.

A study published in the June issue of the Journal of Trauma compares outcomes between two groups of patients. The patients in the first group were intubated for combativeness. The patients in the second group were similar patients in all aspects, yet they were not intubated.

The results of this study are not surprising. When intubated for combativeness, patients had longer hospital stays, more frequent respiratory complications and poorer discharge status.

The authors proposed that combativeness in some patients could be a manifestation of a traumatic brain injury even if a CT head was negative for acute pathology. It is true – some patients with head injury could have an unremarkable CT scans.

The authors also suggested using sedating medications like Haldol and Benzodiazepines to control agitation and avoid intubation.

In my personal experience, many combative patients “fail” a less radical sedation prior to being put on a ventilator.

Interestingly, even though this is a very recently printed article, it was submitted for publication back in July of 2006. Using a newer drug Precedex might be helpful to control extreme agitation. Next time I get asked to see a patient with “respiratory failure from being obnoxious” I will suggest it to the surgeon.

When I was called to see the patient after a motorcycle accident I expected the worst. The patient sustained a thoracic spine injury with cord transsection at T5 level as well as significant chest wall injury on the right side.

Multiple ribs were broken; some with a significant displacement (see the upper image above). Managing patients with a significant chest wall trauma could be a nightmare. Pain control is only one of the challenges.

Mechanics of the respiratory mechanism is impaired. Patients often are unable to take a deep breath and fully expand their lungs. Clearance of the secretions is a concern as well. Many patients with severe chest wall injury succumb to pneumonia and respiratory failure.

To facilitate pulmonary clearance, improve pain control and pulmonary mechanics chest wall stabilization has become a practical option. The technique of realigning and stabilizing ribs with metal plates is yet to be widely adopted. I have witnessed on multiple occasions that the patients with a stabilized chest do better and recover faster then the patients treated conservatively.

I was surprised to see that the patient was, actually, doing Ok from the respiratory standpoint. He was describing that he could feel his whole right side of the chest shifting when he was being moved. Besides that, pain was not a major issue and his respiratory status, otherwise, was stable.

The explanation for this surprising “wellness” was not in any way satisfying. He also sustained a severe spine injury with cord transsection at T5 level. His sensory level was just below his nipples. The patient simply could not feel the pain from the chest injury.

In no way I can call it even a mixed blessing. Most of us would likely take severe pain over being paralyzed.

It did make me think, nevertheless, about the importance of pain control in these trauma patients. Huge doses of narcotics are often unable to control the discomfort. Epidural analgesia is frequently employed to alleviate the pain. Some centers even utilize pain control techniques like intercostal blocks to achieve analgesia.

This is Part 2 of the post on the motorcycle helmet law.

Click Here to read Part 1

So, if there is overwhelming evidence that helmets do save lives, why is there so much controversy about it? Why do only a handful of states have mandatory helmet laws?

Obviously, the law would not have been repealed without strong support from the anti-helmet advocacy groups. There are several arguments that have been presented as a reason for why not to wear a helmet.

Helmets can decrease peripheral vision and hearing. Helmets can exacerbate cervical injuries due to the added weight of the helmet. And the most important one – helmet laws violate individual rights and infringe on personal freedom.

Several studies have shown that helmets do, indeed, decrease peripheral vision by approximately 20%. This reduction, however, is small and was shown to have no impact on motorcycle safety or collision rates.

In terms of the increased rate of cervical spine injury the evidence is somewhat contradictory. Some studies found no increased rate of spine injury. Other studies have shown an increased rate of cervical spine injury, yet there was no difference of the spinal cord injury. As far as I am concerned, cervical spine injury is a fixable problem as long as the brain and the spinal cord are intact.

So, if there are proven benefits of wearing a helmet and no real reasons to not to, why there is still so much disagreement about it? At the end of the day it all comes down to individual rights and personal freedom. If somebody prefers to live on the edge and take the chance of a severe head injury in a motorcycle wreck – why not let them?

And that is where the quandary begins. It is an individual right to not wear a helmet that becomes a burden to society of caring for this individual after the accident. A study conducted by the American College of Surgeons showed that more unhelmeted trauma patients have no medical insurance than trauma patients wearing a helmet (29% vs. 21%).

The same study showed a significantly higher resource utilization use with the unhelmeted trauma patients. And this is just the tip of the iceberg. Most healthcare expenses for the head injured patients occur later during the rehabilitation and placement phases of their recovery. Many patients remain permanently disabled and never return to gainful employment.

If the patient has no insurance, it becomes the taxpayer’s responsibility to provide funding for the long term medical care. Even for insured patients, the tremendous cost of caring for the chronically disabled head injured patient reflects in higher insurance premiums and overall healthcare costs. The individual choice of ignoring personal safety becomes a burden for society.

There is a flip side of this issue, though. If I was a lobbyist for the helmet-free group, I would focus not on the technical reasons for not wearing a helmet but on the social ones. The healthcare expenses for providing care for the head injured patients after motorcycle accidents is a drop in a bucket when compared to more common “lifestyle related” conditions.

You can easily enforce the helmet law, yet you cannot write a ticket for smoking, fast food binging, not exercising or not taking your medications.

Conditions like COPD (chronic obstructive pulmonary disease), congestive heart failure, and heart diseases are the big ticket items on the healthcare spending menu. Those are the things that could bankrupt Medicare. If smoking and abusing one’s body is considered a personal freedom, not wearing a helmet might not be much different…

According to the four seasons of trauma – summer is a motorcycle season. I am “fortunate” enough to live in a state with no mandatory helmet law. It is nice to know that my personal freedom of not protecting myself with a helmet is protected.

I do not ride a bike. I live on the opposite side of this issue – I treat patients in the trauma ICU. Not surprisingly, with the onset of warm weather we have had an influx of motorcycle trauma patients. A very recent encounter made me think about the helmet law, personal safety and the role of society to care for the trauma patients.

19 year old girl was admitted as a trauma patient with multiple orthopedic injuries including pelvic fractures and fractures of her lower extremities. The patient did not sustain any head injury and was neurologically intact. Her boyfriend let her use his helmet when they were getting on the bike. The boyfriend was pronounced “dead on arrival” due to an overwhelming head injury. Is it possible the he gave her a generous “gift of life” by letting her use his helmet?

This is an isolated encounter, though. It has a significant emotional burden, yet, speaking in scientific terms, is not "statistically significant”. One unfortunate death is not a “representative sample”. To find more meaningful data I delved into Ovid database to find the most recent scientific evidence. I was using terms “helmet” and “head injury” to narrow down my search results.

There was no lack of data. Multiple and multiple studies have shown that helmets do save lives and prevent severe head injuries. The evidence is simply overwhelming. One study found that helmets were 37% effective in preventing death and 65% effective in preventing brain injury.

It seems puzzling to me that we have a universal seatbelts law, yet only 21 states in the Union have a mandatory helmet law. You do not need to conduct a study to figure out that riding a motorcycle is far more dangerous than driving a car – there is no metal shell around you body, there are no restraints, either. Indeed, the federal government estimates that motorcycle deaths are about 35 times that for automobiles per mile traveled.

So, if motorcycle helmets save lives, why there is no uniform mandatory helmet law? Like many things in America, this is more a political than a policy question. In 1995 Congress lifted federal sanctions against states with no helmet law. Congress just could not stand the pressure of anti-helmet lobbyists.

One could argue that personal freedom and the freedom of choice prevailed in this case. What about common sense? If wearing a helmet is good for and not wearing one can kill you, we should see more motorcycle related deaths, right? The study conducted in Pennsylvania showed just that.

The Pennsylvania motorcycle helmet law was repealed in 2003. The helmet use among riders in crashes decreased from 82% to 58%. Head injury deaths increased 66%; non-head injury deaths increased by 25%. Motorcycle related head injury hospitalizations increased 78% compared with 28% for non-head injury hospitalizations.

It begs the question – what’s more important – the personal freedom of being stupid or the benefit for society as a whole from the decreased burden of motorcycle related head injuries?

For the purpose of keeping the post short the issue of the socioeconomic burden of the motorcycle related head injuries and helmet law will be explored in Part 2 of this post. Stay tuned.

Hip fracture is a huge problem among the elderly population. It is estimated that more than 300,000 patient are being hospitalized each year for hip fracture in the US alone. The medical cost of hip fractures exceeds 8 billion annually.

Elderly patients are particularly prone to this injury for two reasons. Elderly people fall more often due to an impaired balance and medications effect. Osteoporosis is also more prevalent among the elderly.

Medical management of the elderly patient with a hip fracture is often challenging.

89 year old male with multiple medical problems including coronary artery disease, congestive heart failure, hypertension, atrial fibrillation and chronic kidney insufficiency presented with a comminuted femur fracture (click on the image above). The patient sustained a fall from a ladder. This patient also was taking Coumadin (Warfarin) with an elevated PT/INR.

The orthopedic surgeon recommended surgery to fix the fracture. The patient was given Vitamin K and FFP (fresh frozen plasma) to reverse his coagulopathy. Diuretics were given to prevent volume overload and decompensation of his congestive heart failure.

Despite aggressive medical management the patient developed progressive renal failure and CHF. This would tremendously increase his peri-operative risk.

Now, here is the dilemma. This patient is at increased risk for surgery and can die on the operating table or shortly thereafter. On the other hand, if the hip is not fixed, the patient will unlikely be able to survive beyond several months. Bedridden elderly patients often succumb to pneumonia and other infections.

As the population is getting older, more and more elderly patients are being admitted with a hip fracture. The decision of taking the risk of surgery or letting the patient be should be made on an individual basis. The patient’s and the family’s preference should, obviously, be taken into the account. Very often, though, we are asked to decide if we should take a huge risk of the surgery or let the patient die slowly from being bedridden. There is never a perfect answer to this question.

Everybody knows – seatbelts save lives. Approximately 35,000 people die each year in car accidents and 50% of these lives could have been saved with appropriate use of seatbelts. For every percent increase in seatbelt use 172 lives and close to $100 million in direct and indirect costs could be saved annually.

This is just statistics. Statistics could be impressive, yet it does not affect us on a personal level as much as a real life stories.

It’s a Sunday afternoon and a gorgeous day outside. A car full of teenage kids gets into an accident. Everybody but one kid is wearing a seatbelt. Everybody is Ok except for this kid who is thrown out of the vehicle and was taken to the hospital.

The kid sustained a C6 – T1 spine injury with cord compromise (see the image above). Now the kid is basically tetraplegic just for not using his seatbelt. This will make you think twice before deciding not to use your car safety restraints. Unfortunately, it’s too late for the patient – this young life is ruined.

I hate to sound like a safety billboard, but please wear your seatbelt.

Excessive alcohol consumption very closely correlates with the frequency of trauma. Up to 40% of trauma patients have positive alcohol level on admission. This is not a surprise - drunken people do stupid things and get in trouble.

The effect of alcohol intoxication on trauma morbidity and mortality has been studied extensively. Some studies even showed a beneficial effect of alcohol on outcome from an isolated head injury.

It is also known that alcohol affects your blood clotting system, thus, increasing the risk of bleeding after an injury. This would negatively affect the outcome after a severe injury.

Apparently, the effect of alcohol on blood clotting is different in men and women. The authors of the study published in the May issue of the Journal of Trauma embark on a “difficult” task of getting people drunk and measuring their clotting parameters. I wonder what it took to be a test subject in this study.

Anyway, the male subjects in this study demonstrated an impaired clotting profile consistent with an increased risk of bleeding if injured while drunk. Interestingly, female subjects did not show similar abnormalities putting them at a lower risk of bleeding after an injury.

The difference has to do with sex-specific hormones in men and women. Estrogens which are female hormones are known to promote clot formation. If this difference in blood clotting and the risk of bleeding in drunk patients is significant for real-life clinical practice remains to be seen. I found it interesting, though, that even in a drunken state, women are more resistant to trauma than men.