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[Meursault]

Gods, you leave a thread alone for a couple years and people wander in and :censored: all over it. It's funny how many things I've mentioned that completely didn't happen, by the way. Time to briefly address the HIPAA-related knowledge deficit.


Are you a lawyer? Can I trust your advice?
No and no. But I'm pretty much regurgitating what the agency charged with enforcing HIPAA says about it. If you happen to be a lawyer, and I've made a mistake, correct me.

What is HIPAA, and what does it mean for me?
The Health Insurance Portability and Accountability Act is a typically long and unclear law governing what health care providers, insurers, and the like do with a broad class of patient information. The most comprehensive source on HIPAA I've found so far is http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html. Try the privacy rule summary.
Here's the most important quote, from the FAQ:

The Privacy Rule does not require you to obtain a signed consent form before sharing information for treatment purposes. Health care providers can freely share information for treatment purposes without a signed patient authorization.

I'm being told that I can't (look at a patient's chart, take any paperwork with me, get an oral report, etc.) because it would be a HIPAA violation. What do?
These cases seem to be due to one of three things: complete ignorance about what HIPAA actually mandates (hint: did they spell it "HIPPA"?), absurdly restrictive compliance policies adopted when the law first went into effect, or laziness, malice, and dishonesty. If it's one of the first two, you might benefit from speaking to a supervisor and/or confidently and repeatedly explaining that disclosures for treatment are permitted. Realistically, though, you can't fix any of these. If it's an organization you deal with regularly, see if your employer can do something about it.

Any interesting threads on this forum? Other sources?
Remember how I mentioned a "HIPAA-related knowledge deficit"? But here's what I dredged up:
http://www.nytimes.com/2011/09/09/u...7713966-aPWs2HDMsgou0r9XdcRkGA&pagewanted=all Some actual HIPAA violations that resulted in fines, via ffemt8978.
http://www.ama-assn.org/ama/pub/phy...ability-act/hipaa-violations-enforcement.page A detailed explanation of the punishments for HIPAA violations.
http://www.emtlife.com/showthread.php?t=10554 Several of the regulars use a press conference about a celebrity death to discuss patient privacy, legal and ethical duties, and how to talk to the media. Great advice from karaya. I'll return to this if I get around to ethics.
Beyond that, the only thing you'll get from searching are examples of people's misconceptions about HIPAA and patient privacy in general.

 

[Meursault]

As my Christmas gift to the forum, I think I'll be adding some abstracts on waste and inappropriate interventions.
I should reiterate that I'm just some guy with several levels of Google-fu and too much free time. This isn't justification for disregarding law, protocol, policy, or ethics. More importantly, though, I have nowhere near a comprehensive education and I do make mistakes. If something in here doesn't make sense or seems dubious, do your own research and/or ask someone, but please don't clutter up this thread with questions.

What's all this about helicopter overuse?
The prevailing opinion among experienced providers here and EMS experts seems to be that helicopter transport is overused. The argument is that, since helicopters are risky and expensive, they should be used only when they effect a meaningful reduction in transport time for patients that will benefit greatly from it. The critics hold that EMS greatly overtriages patients to air transport and that, in many cases, flights don't save enough time over ground transport to make any difference.
I don't have enough information to give a good summary of a different argument, which centers on helicopters as a means of delivering advanced providers and equipment to scenes and sending hospitals in order to stabilize patients in the field.

http://www.emtlife.com/showthread.php?t=16068 The forum responds to Dr. Bledsoe's strongly-worded critique of HEMS
http://www.emtlife.com/showthread.php?t=18012 A shoddy scenario turns into a discussion of the appropriateness of cancelling HEMS and how to interact with them in general.
http://www.emtlife.com/showthread.php?t=9523 Repost of a letter from the chief at Maryland's Shock Trauma Center defending their HEMS program.
http://www.emtlife.com/showthread.php?t=25063 "Helicopter shopping"*, competition among services, ETAs, and what happens when you call to request a helo.

*"Helicopter shopping" is, roughly, the dangerous and unethical practice of calling multiple services to get a flight in bad weather without sharing weather information or the fact that you've already been turned down.​

http://www.emtlife.com/showthread.php?t=21211 Maryland-bashing, plus some interesting discussion between flight medics.
http://www.emtlife.com/showthread.php?t=21105 An example of the rarest sort of threads: intelligent, in-depth discussion of a study. This one is on the impact of HEMS on survival. It died of neglect within four posts.
http://www.emtlife.com/showthread.php?t=14476 usaf rants about obstacles to HEMS safety improvement.
http://www.emtlife.com/showpost.php?p=101412&postcount=10 MSDeltaFlt interrupts another crash discussion to caution people with no experience about "jumping on a bandwagon" and speculating.

If you're curious about the number of aeromedical deaths, look at the National Aeromedical Memorial. It doesn't have rate per thousand transports, but I'm sure you can find that somewhere.

 

[mycrofft]

I forget this was here, and it is a sticky. Sorry.

:unsure:

 

[Meursault]

Back to the spine.

I figured I should pull out all the stops for post #500. Sorry about the US-centric approach, and if you have corrections, additions, or better sources, let me know as soon as possible. Also, I have only the faintest idea of statistics, let alone Bayesian statistics. If anyone could contribute something on the low pre-test probability of c-spine injury and its effects on the accuracy of decision rules, please do. Finally, I consistently ignored distinctions among spinal injury, spinal fractures, and spinal cord injury, though I try to report which was measured. I don't think it's relevant enough to justify the added headache.

Why are so many people here critical of spinal immobilization?
It's not just here; haven't you ever taken a patient into the ED and seen them off the board before you left the room? To summarize, spinal injuries aren't that common, occult spinal injuries are quite rare, EMS immobilizes a very large number of people, there are indications that long spine boards do very little good and some harm, and there are rules that can be used to more accurately determine which patients may have spinal injuries. Very few people argue against attempting to immobilize known or likely spinal injuries; more commonly, it's claimed that we're not doing a very good job of it.

How common are traumatic spinal injuries?
The National Spinal Cord Injury Statistical Center reports a US incidence of around 40/million/year nonfatal spinal cord injuries, which it says is a composite of estimates from several studies. The publications I've found are either extrapolations from a nationwide sample or studies of smaller areas. One study using the National Trauma DataBank found a rate of 1.99/100,000/year spinal cord injuries in US children. At the opposite end of the spectrum, a prospective study of ~6000 men over 65 found a rate of 2.2/1000 person-years. A single-year study in Beijing identified 60.6/million/year cases of spinal cord injury. Norway is going strong at an average 21.2/million/year over the last decade.

What we'd really like to know, of course, is how many falls/MVAs/etc. result in spinal injury. I was equally unsuccessful in turning up very much research on that, but one study of 1335 patients with blunt head trauma identified 13 c-spine injuries, for a rate of 0.7%. As a surrogate for the total number of people suspected of having spinal injury, the authors of the NEXUS study (below) estimate that 800,000 c-spine studies are ordered each year in the US. In the NEXUS study, 2.4 percent of the sample, all of whom presented to the ED after blunt trauma, had spinal injuries.

Even patients otherwise injured don't seem to have very many spinal injuries. To quote a meta-analysis, "Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability". "Clinically unevaluable" here means that they're unconscious or have distracting injuries. In the previously-mentioned blunt head trauma study, neither decreased GCS scores nor "severe facial trauma" were associated with c-spine injury (though there were only 13 c-spine injuries). A study of patients with GSWs to the head, neck, or torso found 327/4204 (7.78%) spinal column injuries.

Can we accurately determine which patients have spinal injuries?
Textbooks and my sample of state EMS protocols direct providers to immobilize patients for a great number of criteria, notably "significant mechanism of injury." For instance, step one of the MA protocols for head trauma is "Ensure cervical spine stabilization and immobilization"; the protocol defines head trauma to include "Superficial injury...". The MA protocols for most traumatic injury direct providers to "[a]ssume spinal injury when appropriate and treat accordingly".

There are two ways to look at this: either EMS providers and their medical/legal oversight are terribly overdiagnosing spinal injuries, or they've completely abandoned the concept of forming a working diagnosis before treatment in this case. I suspect the latter, but for the sake of argument and my remaining tatters of idealism, we'll assume the former.

A certain amount of caution is necessary in the treatment of patients with possible spinal injury; occult spinal injuries do happen. A retrospective review of patients with thoracolumbar fractures found 10/537 (0.19%) cases of asymptomatic fracture in "reliable" patients. In the NEXUS study (yes, I'll link to it shortly), 8 of the 34,069 c-spine injuries were cleared by the criteria they used. There are a ton of other papers around, but I believe the point is clear.

Is there a better alternative to mechanism of injury?
A group of researchers were so unimpressed with the standard "board, collar, and image everything" approach that they developed a simple, specific set of rules to determine when patients with blunt trauma don't have c-spine injuries. They're known as the NEXUS criteria after the study. Some areas, notably Maine now allow EMS providers to perform "selective spinal immobilization" using criteria based on the NEXUS trial. In Canada, a field trial of a different rule with a similar approach went fairly well and the authors want to use it more broadly. Another study in the US was similarly optimistic.

The NEXUS and Canadian criteria require judgment in their application. What is a distracting injury? What does it take for a patient to be intoxicated? How altered is altered mental status? To quote the authors, "[W]e believe that evidence of intoxication and the level of alertness are best evaluated on the basis of clinical judgment, rather than laboratory tests or uniform criteria. " The Canadian study noted that paramedics tended to apply the rules more conservatively than indicated, but we could imagine inappropriate underapplication as well.

The NEXUS criteria only cleared 12.6% of patients. The authors point out that this is still a considerable savings in time, money, and exposure to ionizing radiation, but inappropriately conservative use could wipe out the benefit entirely. In any case, applying the criteria in the field isn't going to cause a disappearance of backboards. But...

Do long spine boards provide a significant benefit? Can they be harmful?
Go back a couple of pages for my first post on this.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143405 An expert panel looks at the literature and comes up with some poorly-explained recommendations. They conclude in favor of using a C-collar and padded board for all suspected spinal injury.

http://www.ncbi.nlm.nih.gov/pubmed/20065766 In stark contrast, this study (abstract only for me) looks at penetrating trauma and finds that the number needed to benefit from immobilization is 1032, the number needed to harm is 66 (!), and patients immobilized prehospitally have an OR of death of 2.06 (!!).

http://www.ncbi.nlm.nih.gov/pubmed/21610441 This abstract from a small cadaver study reports that log-rolling patients off a board creates appreciable movement in an unstable c-spine, even with experienced people providing manual stabilization.

http://www.ncbi.nlm.nih.gov/pubmed/21183526 The irony was too good to pass up.

Weren't you originally supposed to be collating forum threads?
Yes, but in cases like this, it makes a lot more sense to go to the research first. I might follow up with threads, but right now it's 0532 and I'm out of shiraz and full of cookies. For now, think, stay safe, and please don't screw around boarding unstable shooting victims.

 

[epipusher]

nice sticky, well done

 

[avendano09]

Just the Begining

Hey guys! Am very new to this thread! This is a great site, and I'm so happy I found it! I'm in Arizona, just applied to CAC (Central Arizona College). I'm starting school this monday, for EMT basic! I am really passionate about people in general, and I've always wanted to be an EMT. How long does this first course last? And yes, I have chosen to keep going with career, eventually going on to Paramedics. I'm nervous and excited, and could use a little advise! Thank you!

Ash

 

[DClemons]

cheers..

Nice link collection on this post - thanks!

 

[rndtuet]

Just replying so I can chat

 

[rndtuet]

enough is enough

Enough is enough

 

[ffemt8978]

Just replying so I can chat

I wouldn't continue to do that if I was you.

Enough is enough

So correct. From our rules

Participants may not bump threads. Bumping can refer to posting useless information, making corrections or updates in a new post, posting one-liners or any other action to deliberately keep a thread hot or to bring it to the top of Recent or Today's Posts. Community Leaders will use their discretion, depending on the nature of the post, as to whether to take action or not.

http://www.emtlife.com/showthread.php?t=8721

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Relevant portions are highlighted.

 

[titmouse]

I hope you were on the clock, cause that's worth monetary compensation.

 

[chaz90]

Are these links bringing people to the wrong threads or is it just me? Wondering if it's a result of the new forum.

 

[vcuemt]

It's ironic that the last post in this thread prior to @titmouse 's untimely (and probably accidental) bump was about bumping zombie threads.

 

[chaz90]

Yeah, but this thread is one that remains valid today.

 

[Meursault]

Are these links bringing people to the wrong threads or is it just me? Wondering if it's a result of the new forum.

Everything I've clicked looked correct. PM me anything that seems off.

 

[titmouse]

It's ironic that the last post in this thread prior to @titmouse 's untimely (and probably accidental) bump was about bumping zombie threads.

lol i did not notice the date mark at all

 

[Rescuelou123]

Hey I'm wondering if anyone took the fdny exam and got a number for the next step.
If so can anyone tell me what I can do next.

 

[Chimpie]

Hey I'm wondering if anyone took the fdny exam and got a number for the next step.
If so can anyone tell me what I can do next.

Over 2,300 responses in this thread: http://emtlife.com/threads/fdny-ems-candidates.35404/