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Lessons on the path from clinician to forensic expert
As physicians, we strive to heal suffering; as psychiatry trainees, we are taught to relieve that suffering through careful assessment, development of rapport, and empathic care. What then of the forensic expert, whose role is to provide the courts with objective assessment of the “defendant,” free of a therapeutic alliance1,2? Learning to navigate between these different roles is a necessary part of forensic training.2
In my journey to become a forensic psychiatrist equipped to treat adults and youth, I’ve had the good fortune to learn from those who appear to have mastered this balancing act. In this article, I present some of those lessons, with the hope that they will resonate with others—both those who are forensically inclined and those who wish to ease the jolt of being subpoenaed to appear before the court.
A day spent in the system
One of my earliest forensic experiences occurred during my training at Johns Hopkins, when I worked in the municipal court. I learned several lessons when I was assigned to pre-screen a defendant for competency to stand trial3 and criminal responsibility,4 both determined by the court but often informed by forensic evaluation.
Lesson #1: Answer only the question that you have been asked. En route to call for the defendant, I scanned my “how-to” guides and was relieved to learn that I was not to serve as decision-maker or treating clinician.5 I realized that I was not being asked to determine guilt or even give treatment recommendations; having a circumscribed task made that first evaluation less overwhelming. Learning to answer only the question you are being asked is a valuable lesson—one that ought to be remembered by those preparing for forensic evaluations and court testimony.
Lesson #2: There is a place for role induction. Entering a nearly empty office at municipal court, I sat behind a large metal desk and waited for the defendant. When he arrived, dressed in orange and escorted by the armed court officer, I rose to my feet awkwardly. I thought that I should shake hands with him, but stopped my hand in mid-air when I saw his handcuffed wrists.
As the guard knelt to chain the defendant’s ankle shackle to the floor, I waited patiently. Once the guard was outside, I introduced myself and read from my script. I explained the purpose of the evaluation and informed him that, unlike a
physician-patient relationship, this evaluation would not be confidential and would be shared with the court in a written report. Although the content of this introductory segment was in stark contrast to my usual patient encounters, this role induction6 was not. The purpose of role induction in a forensic setting is not to affect prognosis, yet such explanation is necessary to maintain ethical boundaries.1
Lesson #3: Know your phenomenology. Proceeding with the evaluation, I inquired about aspects of the defendant’s life. I attempted to assess his knowledge of the charges against him and how the court works,3 and obtained his account of the reported criminal events.4 Having an interest in psychotic illness and an appreciation for Jaspers’ descriptions of psychiatric phenomenology,7 I confidently delved into questions about the source, number, quality, and content of the voices he reported hearing.
Although not fail-proof, knowledge of phenomenology is necessary to discern whether reported symptoms should be trusted.8,9 In his writings10 and during my brief mentorship by him, Phillip Resnick, MD, stressed the importance of being able to detect malingering through knowledge of classic phenomenology and by maintaining a healthy level of suspicion.
Lesson #4: Impartiality is difficult but necessary. I concluded the interview, thanked the defendant, and asked if he had any questions. He declined. I motioned for the court officer to enter the room, unshackle the defendant from the floor, and escort him out. Exiting the room, I turned off the lights and shut the heavy door. The coldness of the physical environment seemed a metaphor for how I felt during the evaluation: In seeking the “truth,”11 had I lost a vital humanistic element?
Performing that early assessment, I felt as if such work challenged the reason I had decided to enter the medical profession. I struggled to see how such objective work contributed to relieving human suffering.
Now, only slightly more seasoned in this trade, I have a better appreciation for this necessarily impartial work. Although the role of the treating provider and the role of the forensic evaluator are distinct,12 both can be rewarding and both provide a valuable service.
Service in the name of Justice
I believe that, by presenting assessments free of bias, one can further the goal of justice: Forensic psychiatry provides the courts with the means to better understand and gain access to the mental health system. The task seemed daunting at first; now, I welcome opportunities to make such contributions to the fair and just treatment of all people.
Disclosure
Dr. Graham reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. American Academy of Psychiatry and the Law. AAPL ethical guidelines for the practice of forensic psychiatry (adopted 2005). http://www.aapl.org/ethics.htm. Accessed August 21, 2013.
2. Strasburger LH, Gutheil TG, Brodsky A. On wearing two hats: role conflict in serving as both psychotherapist and expert witness. Am J Psychiatry. 1997;154(4):448-456.
3. Mossman D, Noffsinger SG, Ash P, et al. AAPL Practice Guideline for the forensic psychiatric evaluation of competence to stand trial. J Am Acad Psychiatry Law. 2007;35(4 suppl): S3-S72.
4. Giorgi-Guarnieri D, Janofsky J, Keram E, et al. AAPL Practice Guideline for forensic psychiatric evaluation of defendants raising the insanity defense. J Am Acad Psychiatry Law. 2002; 30(2 suppl):S3-S40.
5. Rappeport JR. Differences between forensic and general psychiatry. Am J Psychiatry. 1982;139(3):331-334.
6. Chisolm MS, Lyketsos CG. Systematic psychiatric evaluation: a step-by-step guide to applying The Perspectives of Psychiatry. Baltimore, MD: The Johns Hopkins University Press; 2002.
7. Jaspers K. Allgemeine psychopathologie. Berlin, Germany: J Springer; 1913.
8. Soliman S, Resnick PJ. Feigning in adjudicative competence valuations. Behav Sci Law. 2010;28:614-629.
9. Taylor FK. The role of phenomenology in psychiatry. Br J Psychiatry. 1967;113:765-770.
10. Resnick PJ. My favorite tips for detecting malingering and violence risk. Psychiatr Clin North Am. 2007;30(2):227-232
11. Palermo GB. Forensic mental health experts in the court—an ethical dilemma. Int J Offender Ther Comp Criminol. 2003;47(2):122-125.
12. Appelbaum PS. A theory of ethics for forensic psychiatry. J Am Acad Psychiatry Law. 1997;25(3):233-247.
As physicians, we strive to heal suffering; as psychiatry trainees, we are taught to relieve that suffering through careful assessment, development of rapport, and empathic care. What then of the forensic expert, whose role is to provide the courts with objective assessment of the “defendant,” free of a therapeutic alliance1,2? Learning to navigate between these different roles is a necessary part of forensic training.2
In my journey to become a forensic psychiatrist equipped to treat adults and youth, I’ve had the good fortune to learn from those who appear to have mastered this balancing act. In this article, I present some of those lessons, with the hope that they will resonate with others—both those who are forensically inclined and those who wish to ease the jolt of being subpoenaed to appear before the court.
A day spent in the system
One of my earliest forensic experiences occurred during my training at Johns Hopkins, when I worked in the municipal court. I learned several lessons when I was assigned to pre-screen a defendant for competency to stand trial3 and criminal responsibility,4 both determined by the court but often informed by forensic evaluation.
Lesson #1: Answer only the question that you have been asked. En route to call for the defendant, I scanned my “how-to” guides and was relieved to learn that I was not to serve as decision-maker or treating clinician.5 I realized that I was not being asked to determine guilt or even give treatment recommendations; having a circumscribed task made that first evaluation less overwhelming. Learning to answer only the question you are being asked is a valuable lesson—one that ought to be remembered by those preparing for forensic evaluations and court testimony.
Lesson #2: There is a place for role induction. Entering a nearly empty office at municipal court, I sat behind a large metal desk and waited for the defendant. When he arrived, dressed in orange and escorted by the armed court officer, I rose to my feet awkwardly. I thought that I should shake hands with him, but stopped my hand in mid-air when I saw his handcuffed wrists.
As the guard knelt to chain the defendant’s ankle shackle to the floor, I waited patiently. Once the guard was outside, I introduced myself and read from my script. I explained the purpose of the evaluation and informed him that, unlike a
physician-patient relationship, this evaluation would not be confidential and would be shared with the court in a written report. Although the content of this introductory segment was in stark contrast to my usual patient encounters, this role induction6 was not. The purpose of role induction in a forensic setting is not to affect prognosis, yet such explanation is necessary to maintain ethical boundaries.1
Lesson #3: Know your phenomenology. Proceeding with the evaluation, I inquired about aspects of the defendant’s life. I attempted to assess his knowledge of the charges against him and how the court works,3 and obtained his account of the reported criminal events.4 Having an interest in psychotic illness and an appreciation for Jaspers’ descriptions of psychiatric phenomenology,7 I confidently delved into questions about the source, number, quality, and content of the voices he reported hearing.
Although not fail-proof, knowledge of phenomenology is necessary to discern whether reported symptoms should be trusted.8,9 In his writings10 and during my brief mentorship by him, Phillip Resnick, MD, stressed the importance of being able to detect malingering through knowledge of classic phenomenology and by maintaining a healthy level of suspicion.
Lesson #4: Impartiality is difficult but necessary. I concluded the interview, thanked the defendant, and asked if he had any questions. He declined. I motioned for the court officer to enter the room, unshackle the defendant from the floor, and escort him out. Exiting the room, I turned off the lights and shut the heavy door. The coldness of the physical environment seemed a metaphor for how I felt during the evaluation: In seeking the “truth,”11 had I lost a vital humanistic element?
Performing that early assessment, I felt as if such work challenged the reason I had decided to enter the medical profession. I struggled to see how such objective work contributed to relieving human suffering.
Now, only slightly more seasoned in this trade, I have a better appreciation for this necessarily impartial work. Although the role of the treating provider and the role of the forensic evaluator are distinct,12 both can be rewarding and both provide a valuable service.
Service in the name of Justice
I believe that, by presenting assessments free of bias, one can further the goal of justice: Forensic psychiatry provides the courts with the means to better understand and gain access to the mental health system. The task seemed daunting at first; now, I welcome opportunities to make such contributions to the fair and just treatment of all people.
Disclosure
Dr. Graham reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
As physicians, we strive to heal suffering; as psychiatry trainees, we are taught to relieve that suffering through careful assessment, development of rapport, and empathic care. What then of the forensic expert, whose role is to provide the courts with objective assessment of the “defendant,” free of a therapeutic alliance1,2? Learning to navigate between these different roles is a necessary part of forensic training.2
In my journey to become a forensic psychiatrist equipped to treat adults and youth, I’ve had the good fortune to learn from those who appear to have mastered this balancing act. In this article, I present some of those lessons, with the hope that they will resonate with others—both those who are forensically inclined and those who wish to ease the jolt of being subpoenaed to appear before the court.
A day spent in the system
One of my earliest forensic experiences occurred during my training at Johns Hopkins, when I worked in the municipal court. I learned several lessons when I was assigned to pre-screen a defendant for competency to stand trial3 and criminal responsibility,4 both determined by the court but often informed by forensic evaluation.
Lesson #1: Answer only the question that you have been asked. En route to call for the defendant, I scanned my “how-to” guides and was relieved to learn that I was not to serve as decision-maker or treating clinician.5 I realized that I was not being asked to determine guilt or even give treatment recommendations; having a circumscribed task made that first evaluation less overwhelming. Learning to answer only the question you are being asked is a valuable lesson—one that ought to be remembered by those preparing for forensic evaluations and court testimony.
Lesson #2: There is a place for role induction. Entering a nearly empty office at municipal court, I sat behind a large metal desk and waited for the defendant. When he arrived, dressed in orange and escorted by the armed court officer, I rose to my feet awkwardly. I thought that I should shake hands with him, but stopped my hand in mid-air when I saw his handcuffed wrists.
As the guard knelt to chain the defendant’s ankle shackle to the floor, I waited patiently. Once the guard was outside, I introduced myself and read from my script. I explained the purpose of the evaluation and informed him that, unlike a
physician-patient relationship, this evaluation would not be confidential and would be shared with the court in a written report. Although the content of this introductory segment was in stark contrast to my usual patient encounters, this role induction6 was not. The purpose of role induction in a forensic setting is not to affect prognosis, yet such explanation is necessary to maintain ethical boundaries.1
Lesson #3: Know your phenomenology. Proceeding with the evaluation, I inquired about aspects of the defendant’s life. I attempted to assess his knowledge of the charges against him and how the court works,3 and obtained his account of the reported criminal events.4 Having an interest in psychotic illness and an appreciation for Jaspers’ descriptions of psychiatric phenomenology,7 I confidently delved into questions about the source, number, quality, and content of the voices he reported hearing.
Although not fail-proof, knowledge of phenomenology is necessary to discern whether reported symptoms should be trusted.8,9 In his writings10 and during my brief mentorship by him, Phillip Resnick, MD, stressed the importance of being able to detect malingering through knowledge of classic phenomenology and by maintaining a healthy level of suspicion.
Lesson #4: Impartiality is difficult but necessary. I concluded the interview, thanked the defendant, and asked if he had any questions. He declined. I motioned for the court officer to enter the room, unshackle the defendant from the floor, and escort him out. Exiting the room, I turned off the lights and shut the heavy door. The coldness of the physical environment seemed a metaphor for how I felt during the evaluation: In seeking the “truth,”11 had I lost a vital humanistic element?
Performing that early assessment, I felt as if such work challenged the reason I had decided to enter the medical profession. I struggled to see how such objective work contributed to relieving human suffering.
Now, only slightly more seasoned in this trade, I have a better appreciation for this necessarily impartial work. Although the role of the treating provider and the role of the forensic evaluator are distinct,12 both can be rewarding and both provide a valuable service.
Service in the name of Justice
I believe that, by presenting assessments free of bias, one can further the goal of justice: Forensic psychiatry provides the courts with the means to better understand and gain access to the mental health system. The task seemed daunting at first; now, I welcome opportunities to make such contributions to the fair and just treatment of all people.
Disclosure
Dr. Graham reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. American Academy of Psychiatry and the Law. AAPL ethical guidelines for the practice of forensic psychiatry (adopted 2005). http://www.aapl.org/ethics.htm. Accessed August 21, 2013.
2. Strasburger LH, Gutheil TG, Brodsky A. On wearing two hats: role conflict in serving as both psychotherapist and expert witness. Am J Psychiatry. 1997;154(4):448-456.
3. Mossman D, Noffsinger SG, Ash P, et al. AAPL Practice Guideline for the forensic psychiatric evaluation of competence to stand trial. J Am Acad Psychiatry Law. 2007;35(4 suppl): S3-S72.
4. Giorgi-Guarnieri D, Janofsky J, Keram E, et al. AAPL Practice Guideline for forensic psychiatric evaluation of defendants raising the insanity defense. J Am Acad Psychiatry Law. 2002; 30(2 suppl):S3-S40.
5. Rappeport JR. Differences between forensic and general psychiatry. Am J Psychiatry. 1982;139(3):331-334.
6. Chisolm MS, Lyketsos CG. Systematic psychiatric evaluation: a step-by-step guide to applying The Perspectives of Psychiatry. Baltimore, MD: The Johns Hopkins University Press; 2002.
7. Jaspers K. Allgemeine psychopathologie. Berlin, Germany: J Springer; 1913.
8. Soliman S, Resnick PJ. Feigning in adjudicative competence valuations. Behav Sci Law. 2010;28:614-629.
9. Taylor FK. The role of phenomenology in psychiatry. Br J Psychiatry. 1967;113:765-770.
10. Resnick PJ. My favorite tips for detecting malingering and violence risk. Psychiatr Clin North Am. 2007;30(2):227-232
11. Palermo GB. Forensic mental health experts in the court—an ethical dilemma. Int J Offender Ther Comp Criminol. 2003;47(2):122-125.
12. Appelbaum PS. A theory of ethics for forensic psychiatry. J Am Acad Psychiatry Law. 1997;25(3):233-247.
1. American Academy of Psychiatry and the Law. AAPL ethical guidelines for the practice of forensic psychiatry (adopted 2005). http://www.aapl.org/ethics.htm. Accessed August 21, 2013.
2. Strasburger LH, Gutheil TG, Brodsky A. On wearing two hats: role conflict in serving as both psychotherapist and expert witness. Am J Psychiatry. 1997;154(4):448-456.
3. Mossman D, Noffsinger SG, Ash P, et al. AAPL Practice Guideline for the forensic psychiatric evaluation of competence to stand trial. J Am Acad Psychiatry Law. 2007;35(4 suppl): S3-S72.
4. Giorgi-Guarnieri D, Janofsky J, Keram E, et al. AAPL Practice Guideline for forensic psychiatric evaluation of defendants raising the insanity defense. J Am Acad Psychiatry Law. 2002; 30(2 suppl):S3-S40.
5. Rappeport JR. Differences between forensic and general psychiatry. Am J Psychiatry. 1982;139(3):331-334.
6. Chisolm MS, Lyketsos CG. Systematic psychiatric evaluation: a step-by-step guide to applying The Perspectives of Psychiatry. Baltimore, MD: The Johns Hopkins University Press; 2002.
7. Jaspers K. Allgemeine psychopathologie. Berlin, Germany: J Springer; 1913.
8. Soliman S, Resnick PJ. Feigning in adjudicative competence valuations. Behav Sci Law. 2010;28:614-629.
9. Taylor FK. The role of phenomenology in psychiatry. Br J Psychiatry. 1967;113:765-770.
10. Resnick PJ. My favorite tips for detecting malingering and violence risk. Psychiatr Clin North Am. 2007;30(2):227-232
11. Palermo GB. Forensic mental health experts in the court—an ethical dilemma. Int J Offender Ther Comp Criminol. 2003;47(2):122-125.
12. Appelbaum PS. A theory of ethics for forensic psychiatry. J Am Acad Psychiatry Law. 1997;25(3):233-247.
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A Basic Approach to Wound Care
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Basal Cell Carcinoma: Hedgehog Pathway Inhibitors and Beyond
Caring for the Polytrauma Patient: Is Your System Surviving or Thriving?
When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.
Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.
At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.
Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.
A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.
All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.
We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
See Dr. Guillamondegui's commentary here.
When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.
Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.
At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.
Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.
A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.
All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.
We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
See Dr. Guillamondegui's commentary here.
When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.
Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.
At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.
Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.
A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.
All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.
We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
See Dr. Guillamondegui's commentary here.