The Curse of the Red Dot

Name That Bone? Radiology images can be really tricky to correctly interpret, this can especially be so in the typical environment of a frantic ED......  which quite frankly is as far removed from the quiet, dark, undisturbed setting as you can get. As a result errors around x-rays are not uncommon.  Here's a quote from the Royal College of Radiologists that makes this very point; Error is inherent in radiology. The available evidence suggests an error rate in unselected radiology practice of between three and five percent. For certain types of specialist examination, where review by sub-specialists has occurred, the quoted error rate exceeds 30%. About 36 million radiological examinations take place in the NHS in England each year, the great majority of which receive a radiologist’s report. A conservative estimate therefore would suggest that close to one million radiological errors occur each year in the NHS. This equates to approximately 4500 a year in an average sized radiology department ie 90 a week. Near misses are even more common RCR Response to Duty of Candour Everyone who works in healthcare knows this.  Everyone tries hard to reduce this.  One of the simple measures most hospitals use is the so called 'red dot' system........... Situation -The Curse of the Red Dot Background A lady in her 60's with very poor mobility secondary to a stroke attended the ED with a history of falling during the night whilst visiting the toilet. She was struggling to mobilise at all, with pain in the left knee. She was seen in the ED and sent for X-ray. On her return the images were reviewed and checked with a senior doctor. The images were deemed to be normal and the patient was sent home with a diagnosis of a soft tissue injury. Radiology contacted the ED two days later to notify us of a missed fracture. On review of the films there was a  clear missed tibial plateau fracture and it was noted that the original image had been ‘red dotted’ by the radiographers

The patient was recalled and subsequent films showed further displacement of the fracture. The patient has been admitted for operative repair.

 1st presentation- Red dotted.. but looks ? normal...

......aha !

Assessment

Good care-  a junior doctor sought advice from a senior doctor In the ‘old days’ of hard copy films, appropriately trained radiographers would place a red dot sticker on films they thought were abnormal. This was a safety feature to reduce the chances of anomalies being missed. Digital images obviously cannot have stickers placed on them, so radiographers now write ‘red dot’ on the image. Just because a radiographer red dots a film does not mean it is definitely abnormal, however it should raise your suspicion and make you look ‘extra hard’

This lady had several images of her knee taken, whilst all were red dotted the fracture was much more clearly visible on some than others.

Recommendation

If you see a ‘red dot’ image  double check and triple check the image AND the patient If you still cannot see what the radiographer seems to be concerned about,  go and ask them what they think they are seeing, they might be wrong……………..but they might be right Make sure you look at all the images taken. Only one may show the abnormality. http://radiopaedia.org/articles/tibial-plateau-fracture http://emedicine.medscape.com/article/1249872-overview http://www.orthobullets.com/trauma/1044/tibial-plateau-fractures Unnecessary Additional Information The image of the radiologist reporting is a tad misleading- its a Sauropod fossil vertebra

'There ain't no party like an SBAR party'

Case Based Learning - 'The single biggest problem in communication is the illusion that is has taken place ' 

George Bernard Shaw

In an attempt to keep the shared learning coming, I am going to try something new in this post.  Rather than pull a series of cases together and combine the learning I am going to share some of the 'SBAR Incident Alerts' I produce for my ED and hospital. Again theses are ALL real incidents. The errors are genuine, and I suspect will be recognisable to all experienced EM clinicians.

The SBAR (Situation, Background, Assessment, Recommendation ) format is one that will also  be familiar to many. It was originally derived from military use and is a really useful tool to aide clear communication.
 

  Where I work we have introduced SBAR type notification as our standard form of documentation for information coming into the ED, be that paramedic alerts or abnormal investigation results.

We have also introduced it to our ED Notes as a summary page to aide handover between clinical teams and in our Clinical Decisions Unit at the end of protocols so that the referring clinicians can clearly outline their expectations for the patient

Used correctly and aye there lies the rub, SBAR use help delivers safer patient care and also protects clinicians.

I HIGHLY recommend considering using it.

Information about SBAR can be found here- NHS Institute for Innovation and Improvement on SBAR

Situation

Missed C2 Fracture

Background

An elderly patient attended from his Nursing Home having fallen on to his face on concrete sustaining significant bruises to his face and head. He had quite marked dementia which made assessment difficult but he seemed to have good neck movement and complained of no localised pain there.

X-rays were taken of his mandible which was deemed to be normal before a plan to admit to Med Eld was made.  The following day he was seen on the ward round and again had no neck pain and was deemed fit for discharge.

He returned to the ED 3 days later as the nursing home staff felt he was more confused than normal.  He was noted to have no ‘neck tenderness’ before being sent for a CT of his head and brain.

The CT confirmed facial fractures, small intra-cerebral haematomas and also showed an off ended PEG (C2) fracture with cord impingement.

He was fitted in an Aspen Collar before transfer to Med Eld for conservative treatment

Assessment

The ED teams initial failure to diagnose the C2 fracture caused no serious harm to the patient however it certainly exposed him to risk and despite repeated ‘no neck pain documentations’ must have caused some him some additional discomfort

Assessing any patient with decreased ability to communicate makes it harder to get things right first time, be that extremes of age, language barriers, intoxication or dementia

Frail elderly people break more easily than you think.

A fall banging the forehead /face is a classic mechanism for PEG fractures (hyperextension of the neck)

They are VERY easily missed

Neck Radiology 

Recommendation

Remember ‘the head bone is connected to the neck bone’  so any facial injury puts the neck at risk

Have a lower threshold than normal for CT imaging of the neck in patients with the right history and decreased communication abilities

 NICE CT Neck Algorithm

College of EM- Neck Imaging 2010 

Remember ’Steel’s rule of thirds’- at the level of C1 the spinal canal consists of 1/3 Cord, 1/3 Bone (peg of C2) and 1/3 space- so there may be no neurological signs (fortunately)

Also remember Central Cord Syndrome can occur late in this group, even without a fracture CC Syndrome

Remember to give good discharge advice with ‘triggers to return’ for patients or their carers

Situation

Opiate Overdose

Background

A 50 yr old lady was found face down on a golf course having apparently taken 200mg of oramorph . Paramedics gave her IM Naloxone on scene and on the way in (800mcg and 400mcg). On arrival at ED her GCS was 15 with normal observations but she did de-saturate off Oxygen

She was seen immediately by a senior doctor and moved to a visible cubicle next to the nurses’ station on a monitor where she chatted to her family. The doctor was drawn into to resus to deal with other patients but came back approximately thirty minutes later to perform an Arterial Blood Gas (ABG). In that 30 minutes the pt had been cannulated, an ECG performed and was conversant with staff and relatives. The doctor noted that the pt was now very drowsy, with an ABG showing a pH of 7.2, CO2 of 8.38 and O2 of 12 (kPa on high flow oxygen)

She was taken to resus where a naloxone infusion was commenced and BiPAP started before transfer to critical Care. She made an uncomplicated recovery and was discharged the following day.

The case was reported as a potential SI in view of the patient’s deterioration, but subsequently downgraded on review of her care records

Assessment

There are many elements of good care;

Good recording of pre-hospital SBAR

Good nursing assessment with immediate discussion with a senior doctor

Immediate review by the senior doctor

Placement of the patient in a highly visible cubicle on cardiac monitoring

What could have been done better?

The treating doctor did not notice the first dose of Naloxone given by the paramedics was 800mcg

Had they done so they may have considered starting an IV Infusion earlier or further bolus doses

Recommendation

Opiate overdoses should be cared for in a monitored highly visible environment with regular documented obs

If obs cannot be measured regularly on a team the patient should be moved to resus

Always read and document what treatment the patient has had BEFORE arrival. It can influence what you need to do

BEWARE of re- narcotisation

Naloxone has a much shorter half-life (30 to 80 minutes) than most opiates especially methadone (4- 8 hours analgesia, 8-59 hours elimination)

Consider a naloxone infusion (BNF- 10mg (25 vials!)in 50mls of 5%dex)